Douglas Krohn, MD
By 2017, the situation had gotten to the point that even the New York Times had incorporated it into its national coverage: Skin infections were dooming athletes and ending careers – their presentations steadily increasing in both drama and frequency – with the abrupt and unanticipated finality that we generally see through more familiar mechanisms, like knee injuries and repetitive head trauma.
New York Giants tight end Daniel Fells, for example, had recently concluded a harrowing ordeal related to an MRSA infection (methicillin-resistant Staphylococcus aureus) – likely contracted on the playing field or in the team’s practice facility – that nearly resulted in an amputation of his foot, and ultimately led to his retirement a few months later at age 32. And just two years before that, an outbreak of MRSA at the Tampa Bay Buccaneers practice facility sidelined three players, requiring intravenous antibiotic administration in at least one of them.
As if these skin infections were injuries whose caliber were akin to an anterior cruciate ligament ruptured in a cutback on the turf, two of the players would never take the field again.
And these cases preceded perhaps the most infamous skin infection in an athlete of all time: Kansas City Chiefs quarterback Alex Smith, who suffered a compound fracture of his leg (in which a broken bone fragment pierced through his skin) during a game, and whose subsequent skin infections led to 17 different surgeries, blood-borne infection, a bout with depression, and chronic pain.
The athletic skin infection epidemic – which is even more prevalent in mat athletes like wrestlers and other grapplers – is not without a preventive remedy, however: The National Athletic Trainers Association (NATA) recommends that athletes at all levels – from youth sports through high school and on to college and the pros – shower with an antimicrobial body wash immediately following practices and games (or as soon as the athlete gets back home). The problem, though, is not the availability of effective preventive therapies. Rather, the issue comes down to compliance.
“It’s like pulling teeth to get the athletes in the shower,” said a high school athletic trainer in that New York Times article. “After practice, they’re sweaty and have dirt and mud on them. In football, they might have cuts, scrapes and abrasions. I say to them, ‘Guys, without a shower, we’re inviting infection.’”
And those infections are most often of a variety unlikely to receive national press coverage: Ringworm, herpes, and impetigo usually do not land an athlete in the hospital, nor threaten life and limb. But they do cause itch and discomfort, interfere with sleep, and worst of all for an athlete, result in exclusion from competition (including high school sectionals and state championships) until the skin has cleared and medical staff has deemed the athlete non-contagious.
In addition, these skin infections often come with stigma and misconceptions about their transmission. Shintaro Higashi, a senior judo competitor and two-time Team USA member at the World Judo Championships, shared his experience with “mat herpes” on his podcast, The Shintaro Higashi Show.
“Everyone was like, ‘Eww, you have herpes.’ It was so shameful.”
In my pediatric practice, I try to be practical about the matter. NATA may suggest showering with an antimicrobial cleanser immediately after sports participation, but I generally instruct my athlete patients to do so within 30 minutes, or as soon as they return home. The open showers in a high school locker room do not appeal to adolescents, who are often extremely private and modest, and few educational institutions are enthusiastic about such arrangements, anyway.
I also counsel patients that, as important as studying may be, take that shower first. Don’t sit in sweaty clothes, finishing your math homework or studying for the social studies midterm, and put off the shower until the end of the night – get the shower out of the way, and you are more likely to study effectively and avoid skin complications that will take you away from your sport.
Neither should dinner delay an athlete’s attention to hygiene. I often suggest that the patients pack a piece of fruit in their backpack for those post-practice hunger pangs, eat it on the way home – and then jump in the shower upon arrival and sit down for a relaxed dinner with the family.
As far as the antimicrobial cleanser itself, I also try to be practical. Gels and body washes are going to be much easier to utilize and much easier to distribute across one’s whole body than bar soap. Likewise, over-the-counter options are much more accessible and usually less expensive than prescription body wash options.
And I try to put some clinical weight behind my recommendations: Body washes that contain sodium hypochlorite (also called “chlorine” or “bleach”) are going to eradicate many more bacteria, fungi and viruses than tea tree oil-containing products – which are popular, but comparatively are not backed by evidence. Similarly, sodium hypochlorite gels offer dual protection in athletes with atopic dermatitis (eczema) – who themselves are at an increased risk of skin infections because of their eczema – in a way that body washes with typical soap or chlorhexidine do not. In fact, the American Academy of Allergy, Asthma and Immunology recommends sodium hypochlorite bathing as an adjunctive therapy in patients with moderate to severe eczema.
Athletic-associated skin infections are common, potentially serious, and sideline thousands of athletes at the interscholastic level, often at the most crucial part of the season, due to mandatory exclusion policies. But there are academy-guided and evidence-based techniques for prevention that are available through numerous retail outlets, and those that foster compliance with ease-of-use and practical application are likely to promote skin health and increase participation in athletes at all levels.