Skin infections (Part 3): Fungal

Hi everyone! I know you’re probably sick of reading about skin infections. However, for the sake of completeness, we need to finish our discussion by talking about fungal skin infections.

Fungi are widespread in the environment. Fungal infections in humans can generally be classified into 3 categories:

  1. Superficial skin infections
  2. Deeper subcutaneous infections
  3. Widespread systemic infections

Today we will be focusing on superficial infections, as these are more common in combat sports. There are many species of fungi that can cause these infections.

Tinea corporis (ringworm)

Tinea corporis is a cutaneous fungal infection occurring in sites other than the feet, groin, face, or hand.

ringworm 1Tinea_crprs_plaq

What to look out for:

  1. Red, scaly, circular or oval patch
  2. Usually itchy
  3. Continues to grow and spread outwards from the center
  4. Central area clears, while an advancing raised border remains (forming a ring-like lesion)

Tinea Pedis (athlete’s foot)

Tinea pedis (also known as athlete’s foot) is the most common fungal skin infection. Infection is usually acquired by means of direct contact with the fungi, as may occur by walking barefoot in locker rooms or swimming pool facilities.

pedis

Interdigital tinea pedis

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What to look out for:

  1. Red, itchy, erosions or scales between the toes
  2. May sometimes be painful

Moccasin-type tinea pedis

superficial3

What to look out for:

  1. Patchy, dry scaling on the soles and sides of the feet
  2. On a red base

Tinea cruris (Jock itch)

Jock itch is common in athletes in the groin region due to copious amounts of sweating and tight-fitting clothing.

Tinea_cruris_3

What to look out for:

  1. Red, itchy patch on the upper and inner part of the thigh
  2. Patch grows and spreads outwards
  3. Central area clears slightly
  4. Red, elevated border that may have tiny fluid filled blisters

Treatment of fungal skin infections

If you notice a fungal infection on your skin, you should stop training and visit a doctor. These infections are contagious and spread via skin-on-skin contact.

The doctor can usually diagnose a simple fungal infection by looking at it. However, ringworm can sometimes be confused with other ring-like skin eruptions. One such example is eczema (treated with topical steroids). If a fungal infection is misdiagnosed and initially treated with a topical steroid, the appearance of the infection may be altered, making diagnosis more difficult. The infection may also worsen (steroids suppress the immune system) and progress to a deep-seated infection of the follicles. (Majocchi’s granuloma). Therefore, the doctor might do a skin scraping and utilize a microscope to confirm the diagnosis.

The doctor might give you antifungal drugs that can be directly applied to the affected area of the skin. Treatment is generally administered once or twice per day for one to three weeks. Oral antifungal drugs may be prescribed for patients with extensive skin involvement and patients who fail topical therapy.

Prevention of fungal skin infections

The same prevention tips for bacterial and viral skin infections still apply. Here are some other guidelines that can help keep fungi away from your skin.

  1. Always wear slippers or sandals when at the gym, pool, or other public areas. That includes public showers.
  2. Dry yourself well after showering (don’t forget your feet and in between the toes!)
  3. Consider using talcum powder for your feet and groin if you have recurring infections

Conclusion

That sums up our discussion about skin infections! I hope this 3-part series has taught you a thing or two about common conditions of the skin. I also hope it has underscored the need to maintain good personal hygiene.

Stay tuned for the next post about cauliflower ear!

 

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Skin Infections (Part 2): Viral

Hello everybody! Today we will be resuming our discussion about skin infections. Besides bacteria, viruses are also a common cause of skin infections. Without further ado, let’s jump straight into the dirty details:

Viral Infections

Viral warts

These common and non-cancerous warts are caused by the Human papilloma virus (HPV). HPV infects the epidermal cells of the skin. Infection with HPV occurs by direct skin contact. Minor skin trauma predisposes patients to infection, though infection may also occur in normal skin. Patients may also spread a wart to an uninfected part of their own skin.  The time period between infection and the appearance of the warts is approximately two to six months.

Viral warts are divided into three main categories: common warts (verruca vulgaris), plantar warts (verruca plantaris), and flat (plane) warts (verruca plana)

Common warts

Verruca_vulgaris_hand_2Verruca_vulgaris

What to look out for:

  1. Dome-shaped thickening of skin that grows outwards
  2. Most common on fingers, top of the hands, knees or elbows but may occur anywhere
  3. Black dots (key defining feature distinguishing it from a corn) on the surface of the warts which can be seen when skin debris on the wart is scraped of with a blade or file. The black dots are actually capillaries and thus bleeding may occur if you pick at the wart

The natural tendency to pick or scratch at existing warts can spread them to unaffected skin, a process known as autoinoculation.

Flat warts

Most common on the top of the hands, arms and face

Flat_warts_foreheadFlat_warts_linear

What to look out for:

  1. Small smooth-surfaced bumps on the skin
  2. Slightly elevated
  3. Flat-topped
  4. Skin-coloured or pink.

Damaging a flat wart (e.g., shaving the neck) may cause the virus to spread, eventually leading to crops of several hundred flat warts.

Plantar warts

plantars-wartLargeplanterwartPlantar_warts_close_view

What to look out for:

  1. Thick wart that grows inwards (rather than outwards like a common wart)
  2. On the soles of the feet
  3. Black dots (capillaries)
  4. Several plantar warts may accumulate beneath the surface of the epidermis, with the surface resembling one large wart.
  5. Plantar warts may be painful when walking

Plantar warts may be mistaken for calluses. Skin lines pass around a wart while they pass through a callus. Warts have the characteristic black dots while calluses do not.

Infection can occur when someone who already has a wart walks barefoot, leaving behind viral particles. The particles can then be picked up by another person who is walking barefoot.

Treatment of viral warts

Most viral warts will go away on their own. For most people, treatment of viral warts is not mandatory. However, it is highly recommended that grapplers avoid training and get their warts removed by a doctor, so that they do not infect their training partners.

A variety of interventions are available for treatment. Common methods include chemical or physical destruction of infected tissue (e.g. salicylic acid, cryotherapy, surgery, laser), or other stronger medications. In general, the approach is dependent upon the type of wart  and influenced by consideration of wart location, treatment side effects, clinician skill, and patient preference.

Molluscum Contagiosum

Molluscum contagiosum is another virus that can infect the skin. It is a common disease of childhood. The disease also occurs in healthy adolescents and adults, often as a sexually transmitted disease (on the genitals) or in relation to participation in contact sports.

Molluscum is spread by direct skin-to-skin contact and thus can occur anywhere on the body. The virus can be transmitted via autoinoculation by scratching or touching a lesion. For example, if the lesions develop on the face, shaving may spread the virus.

Infection can also be spread via fomites (any object or substance capable of carrying and transferring infectious organisms) on bath sponges or towels or through skin contact during participation in contact sports  An association of molluscum with swimming pool use also has been reported.

The time period between infection and the appearance of the characteristic bumps on the skin is between two and six weeks.

molluscum_contagiosum_genitalMolluscum_neck

What to look out for:

  1. Firm, dome shaped bumps (2 to 5 mm in diameter) on the skin
  2. Shiny surface and central indentation
  3. May appear anywhere on the body except the palms and soles. The most common areas of involvement include the torso, armpit, crook of elbow, behind the knee, and inner thigh

Treatment of molluscum

In most patients, individual lesions usually spontaneously resolve within two months and the infection often clears completely within six to twelve months. In a minority of cases, disease persists for three to five years

It is technically possible to continue training while infected with molluscum. Care must be taken to reduce the risk of transmission to others. Bumps in areas that are likely to come in contact with others should be covered with a watertight bandage and a rashguard.

The main issue with this is that smaller bumps that are harder to notice may not be covered up, and your partners may still end up getting infected. Therefore, train at your  own (or your partners’) risk.

Regardless of whether you decided to stop training, it is recommended that grapplers get their molluscum treated by a doctor. Like viral warts, there are many methods available (cryotherapy, lasers etc.)

Herpes Simplex Virus

Herpes simplex virus type 1 (HSV-1), also known as herpes labialis, is the virus responsible for “cold sores” on the mucosa of the mouth. (HSV-2 is responsible for herpes on the genitals)

HSV-1 may be associated with combat sports, where it is often called Herpes gladiatorum (a.k.a. wrestler’s pox, mat pox). Transmission is primarily by direct skin-to-skin contact and abrasions may facilitate a portal of entry.

herpes-simplex

What to look out for:

  1. Early stage (<6 hours): Itching, tingling or burning sensation followed by:
  2. Clustered, small, painful, fluid-filled blisters on a red base which heal with crusts over about 1 to 2 weeks.
  3. Headache, generalized illness, sore throat and fever may be reported.
  4. May lead to recurrent infections, as the virus can hide and remain dormant within your nerves

Herpes simplex may be confused with early impetigo. Accurate diagnosis requires laboratory testing by the doctor.

Treatment of Herpes gladiatorum

It is important to stop training as soon as possible and see the doctor. Treatment of herpes gladiatorum is with oral aciclovir or similar agents and is most effective if commenced at the first symptoms of an outbreak (<48 hours after onset of blisters). Topical aciclovir may also be given.

How to prevent viral skin infections

Besides the general guidelines that were recommended in Part 1 of the series, here are a couple more recommendations:

  1. Do not share towels or bath sponges
  2. Wear flip-flops in communal showers. While this may seem a little extreme, walking barefoot on a wet floor may put you at risk. It is worth mentioning that my microbiology tutor, a part-time rugby coach in his free time, insists on wearing flip-flops in communal gym showers.
  3. If you do have a viral skin infection, do not pick and scratch at the bumps. This is a good way to avoid autoinoculation.

Conclusion

Viral skin infections can be a real pain. However they tend to be a little less serious than bacterial infections. With appropriate treatment, they are usually easy to deal with. Stay tuned for the final part of the series, where I’ll be talking about fungal infections!

 

 

Skin Infections (Part 1): Bacteria

“Staph” – the mere mention of the word strikes fear into the hearts of grapplers everywhere. Skin infections are pretty common in grappling due to the large amount of skin-on-skin contact. These infections can be caused by bacteria, viruses, fungi or any other parasites. Today, we will be talking about bacterial skin infections.

To understand skin infections, we first need to understand the anatomy of the skin:

Skin-Anatomy-2

The skin essentially has 3 layers: epidermis, dermis and subcutaneous tissue. Any one of these layers can get infected. In general, the deeper the infection, the more serious it is.

Everyone knows about staph ( a.k.a Staphylococcus aureus).  However, Streptococcus pyogenes is also a very common cause of skin infections.

Warning: Some of these images are pretty graphic

Overview of bacterial skin infections

Screen Shot 2016-07-06 at 6.56.15 pm

Impetigo

Impetigo is a highly contagious infection of the superficial layer of the epidermis. It can be caused by both staph and S. pyogenes. Impetigo can happen when bacteria invade an area of normal skin or when there is infection of areas of minor skin trauma (cuts, abrasions, eczema).

Non-bullous impetigo

This is the most common form of impetigo (70% of the cases)

impetigo

What to look out for: It starts out with papules (small swellings of the skin), that progress to become vesicles (small fluid filled sacs) lying on an area of redness. The vesicles then rupture to form the characteristic honey-coloured crust on a moist red base.

Bullous impetigo

Less common in adults and less contagious.

MRSA3

What to look out for: the vesicles enlarge to form fluid filled bullae (larger blisters) with clear yellow fluid, which later becomes darker and more cloudy. Ruptured bullae leave a thin brown crust.

Bullous_impetigo_crusting

Treatment for impetigo

If you have impetigo, you need to stop training and see the doctor! It is highly contagious and you can easily spread it to your training partners via skin-on-skin contact. Do not share towels, gis or any other gear/equipment with anyone.

The doctor will give you topical antibiotics such as mupirocin and depending on how widespread the impetigo is, he/she may give you an oral antibiotic such as augmentin.

Don’t worry! Impetigo goes away pretty quickly with treatment and it usually does not leave any scars.

Erysipelas and cellulitis

Cellulitis and erysipelas are infections resulting from bacterial entry via breaches in the skin barrier. They are deeper infections than impetigo as they involve the dermis and are thus more serious. Erysipelas involves the upper dermis and superficial lymphatics while cellulitis involves the deeper dermis and subcutaneous fat.

Erysipelas

erysipelas-pictures-4

What to look out for: A painful area of redness, swelling and warmth. The lesion is usually raised above the level of the surrounding skin and there is a clear boundary between infected and non-infected skin. Patients with erysipelas tend to have systemic symptoms such as fever and chills.

Cellulitis

cellulitis_05_

What to look out for: A painful area of redness, swelling and warmth. The lesion is not raised and there is no clear boundary between infected and non-infected areas. Patients with cellulitis tend to have a slower and less aggressive course with development of localized symptoms over a few days’ time, though fever and chills may still occur.

Treatment of erysipelas and cellulitis

Unlike impetigo, erysipelas and cellulitis are not contagious as they involved the deeper dermis layer of the skin. However, it is still wise to stop training, because you may be systemically unwell (fever, chills etc.). It is essential that you see a doctor because antibiotics must be given.

IV antibiotics are needed if you have a severe infection, while oral antibiotics are sufficient for most patients who are systemically well.

Abscesses, furuncles and carbuncles

Skin abscesses are collections of pus within the dermis and deeper skin tissues. A furuncle (or “boil”) is an infection of the hair follicle in which pus and other material extends through the dermis into the subcutaneous tissue, where a small abscess forms. A carbuncle is a coalescence of several inflamed follicles into a single inflammatory mass with drainage of pus from multiple follicles.

All 3 can develop in healthy individuals with no predisposing conditions other than skin or nasal carriage of Staphylococcus aureus. Any process leading to a breach in the skin barrier can also predispose to the development of  skin abscesses, furuncles, or carbuncles.

Skin abscesses

Skin_abscess

Blausen_0007_Abscess

What to look out for: A painful, fluctuant (movable and compressible), red nodule, frequently surmounted by a pustule (pus containing blister) and surrounded by a rim of redness and swelling. Fever, chills, and generalized illness are not common.

Furuncles

furuncle-pictures

What to look out for: Similar to an abscess (hard, tender, red, fluctuant nodule), but centered around a hair follicle. May discharge pus and may be associated with fever and generalized illness.

Carbuncle

Carbuncle_new_2

156x150_carbuncles_ref_guide

What to look out for: Swollen painful area discharging pus from several points. May be associated with fever and generalized illness.

Treatment of abscesses, furuncles and carbuncles

Abscesses, furuncles and carbuncles are contagious. Thus you need to stop training. (are you starting to see a trend here?). They also may cause scars (more incentive to get them treated early).

For small furuncles, warm compresses to promote drainage are usually sufficient treatment. Larger furuncles, carbuncles, and abscesses require incision and drainage by a healthcare professional.

Oral antibiotics may be given if there are multiple lesions, a single abscess ≥2 cm, extensive surrounding cellulitis, signs of systemic infection, or inadequate clinical response to incision and drainage alone.

Necrotizing fasciitis (A brief mention)

There has been plenty of talk in the media about deadly “flesh-eating” bugs. This usually refers to necrotizing fasciitis, which is an infection of the deeper subcutaneous tissues that results in progressive destruction of the muscle fascia and overlying subcutaneous fat, and has a high mortality rate.

Necrotizing fasciitis is not caused by any special “flesh-eating”  bacteria. They are usually caused by good ol’ staph and S. pyogenes. The same organism can cause infections of differing severity depending on the layer of skin involved.

Thankfully, necrotizing fasciitis is extremely rare. It usually occurs to individuals after surgery or severe trauma (car accidents etc.). Other conditions associated with necrotizing soft tissue infection include diabetes, drug use, obesity and suppressed immune systems. Thus it is unlikely that the average grappler will get necrotizing fasciitis.

No images because they are all excessively gory (Google at your own risk)

What to look out for (just in case):

The affected area may be red (without sharp margins), swollen, warm, shiny, and extremely painful. The pain is usually out of proportion to the size of the lesion.

The process progresses rapidly over several days, with changes in skin color from red-purple to patches of blue-gray. Within three to five days after onset, skin breakdown with large blisters (containing thick pink or purple fluid) and gangrene can be seen. By this time, the involved area is no longer tender but has become numb secondary to clotting of small blood vessels and destruction of superficial nerves in the subcutaneous tissue.

Treatment of necrotizing fasciitis

Necrotizing fasciitis is an emergency. IV antibiotics and surgery is absolutely necessary to save the patient’s life. If you have necrotizing fasciitis, training BJJ will be the last thing on your mind.

Antibiotics and resistance

While it is true that antibiotic overuse has led to the rise of antibiotic resistant bacteria, antibiotics should not be avoided if you have a serious skin infection. In situations like this, antibiotics (+/- incision and drainage) are critical in ensuring that an infection does not spread. Therefore, it is wise to seek medical help whenever you suspect you have a bacterial skin infection.

There has been a rise in the prevalence of community acquired MRSA (Methicillin-resistant Staphylococcus aureus) in many countries, though it is still pretty rare. This is a cause for concern. MRSA is usually a hospital acquired infection (antibiotics are spammed in hospitals and the bugs that survive tend to be uber tough). However, many people on the internet make MRSA out to be some sort of unstoppable monstrosity that kills simply by touch. MRSA is still sensitive to some antibiotics, such as vancomycin. Thus getting an MRSA infection is not a death sentence (though it is still extremely serious).

Prevention of bacterial skin infections

There has been much debate about the need for special soaps (Defense soap etc.) for grappling. I will not discuss the pros and cons of the various soap types out there. The results are pretty controversial and I am simply not well-read enough or qualified to pass judgment.

However, I believe that all this argument detracts from the main point: don’t be a disgusting Neanderthal that neglects personal hygiene. 

Preventing bacterial skin infections is not rocket science. Here are some simple guidelines:

  1. Shower after class. You can use whatever type of soap you want, but make sure you scrub your body properly.
  2. Do not train with open wounds. Your skin serves as your body’s first line of defense against pathogens. Training with an open wound is akin to going to battle with a shield full of holes. Cover up your wounds!
  3. Don’t train with anyone that has a skin infection. Now that you know what the common bacterial infections look like, make sure you look out for them on your training partners.
  4. Train in a clean academy. Make sure your academy cleans their mats regularly.
  5. Don’t be that guy who trains in unwashed gis/training attire. Make sure you change and wash your gear regularly.

Conclusion

Bacterial skin infections suck. They take away precious time on the mat and are frankly quite disgusting. Good personal hygiene can help prevent the dreaded staph and S. pyogenes infections. However, if you do happen to get infected, don’t panic! Most skin infections are not that serious and are easily treated.

Stay tuned for the rest of the series, where I talk about viral and fungal skin infections.