“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:
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
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).
This is the most common form of impetigo (70% of the cases)
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.
Less common in adults and less contagious.
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.
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.
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.
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.
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.
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.
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:
- Shower after class. You can use whatever type of soap you want, but make sure you scrub your body properly.
- 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!
- 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.
- Train in a clean academy. Make sure your academy cleans their mats regularly.
- Don’t be that guy who trains in unwashed gis/training attire. Make sure you change and wash your gear regularly.
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.