Other skin problems

Blisters

Friction blisters are a common problem on the feet of athletes and can cause pain or pressure. They usually represent a separation of the epidermis from the dermis and the subsequent inflammatory response produces fluid which sits within the blister as the blood vessels in the dermis become more permeable and leak to produce a serum-based fluid. The fluid contains cytokines and growth factors released by the damaged keratinocytes which then brings in immune cells to create the best environment for healing.

The fluid within the blister is therefore important and plays a significant role in protecting the damaged dermis as it heals through cushioning and immune mediators. In a similar manner to wet healing, the roof of the blister allows epidermal cells (keratinocytes) to grow over the surface of the raw area and the dermis contributes fibroblasts which synthesise new collagen and contributes to the skin’s elasticity.

To manage the blister, if the roof is intact, then leaving it so and covering with an anti-friction or protective dressing such as gel squares and fixation tape will allow most blisters to settle.

Occasionally intact blisters have a mass effect that can interfere with management and can be de-roofed in a sterile manner. Open blisters should have the skin flap removed and a clean dressing applied.

Skin blisters are common and should generally be left intact and protected unless painful or causing mass effect.

Scrumpox (Herpes Rugbiorum)

Herpes infections of the head and neck are common. They are caused by the herpes simplex virus from direct skin contact between individuals with an active infection e.g., cold sores. The rugby version is scrumpox (herpes rugbiorum) and is common around the mouth, face and ears. 

The virus permanently lives in the ganglion of the nerve that supplies the skin of the acute primary infection and reappears from time to time. Symptoms to note are sensitivity to light touch of the skin around the scalp or face that is soon followed by a small number of vesicles/ blisters somewhere on the skin in that nerve distribution – typically around the ear or external auditory meatus. At this stage the player is highly contagious and at risk of passing on to colleagues. If caught at this stage, the attack can be prevented by early high dose of a systemic oral antiviral agent such as Valacyclovir.  

Many players, however, have minor symptoms so often that they are used to them and so do not declare them. This leads to the infection spreading before it is noticed. All potential lesions should be covered with topical anti-viral and direct skin-to-skin contact with others avoided. A small number of players, particularly those with a primary infection will describe severe lancinating pain on light touch such as combing their hair.

Pain management can be difficult. Once the blisters crust, then the player is no longer infective and restrictions on contact training can be relaxed.

Ringworm

Despite its name, Ringworm is caused by the fungus Tinea. It is the most common skin infection described in sport and the fungal spores thrive in the sweaty sports environment. It presents as painless erythematous and scaley patches with a prominent external rim. Treatment involves covering the lesions for training and games and a course of topical antifungal agents until the lesions have resolved. E.g., Terbinafine cream.

Some parts of the body such as the face, may require treatment with tablets rather than creams. 

Impetigo

Impetigo is a highly infectious superficial bacterial skin infection with a typical gold-crusted appearance in multiple plaques or spots. It is typically caused by the bacteria Staphylococcus Aureus and lesions should be treated with prevention of physical contact (if possible, dressings and no rugby due to its highly infectious nature) and topical or systemic antibiotics with good gram positive cover such as Flucloxacillin, Co-amoxiclav or other depending upon local policy. 

Management of thickened callus

Highly active people will develop a natural thickening of the skin over certain bony prominences that appear as hard calluses. For example, on the feet or palms of hands from gripping and lifting in the gym. Whilst not a problem in themselves, they can become inflexible causing shearing of nearby skin and blisters or themselves crack and bleed. Given the thickness of the epidermis on the callus, the lack of flexibility can mean that healing is slow and there is a cycle of recurrent skin injury. Maintaining a healthy skin and preventing callus becoming excessive is an essential part of maintaining skin health. Regular moisturising and use of a wet pumice stone to gently rub away at areas of developing callus will prevent cracking and potential infection with pain and potential time loss.

Hard cracked callus should be managed with softening over weeks via a pumice stone.

Skin cancer – Malignant Melanoma

Players may be exposed to a large number of hours of sunlight and thus ultraviolet radiation each year. 

Malignant Melanoma is a type of cancer caused directly by ultraviolet radiation that can be treated if it is identified early in the disease process. It can affect all skin colours and is most common on the head, neck and backs of males, legs of females and in odd sites such as under toenails (a Sub-ungal Melanoma) or the sole of the foot on black or people of colour. Odd sites such as under toenails may often be confused with bleeding under the nail from trauma or chronic irritation by footwear.

It usually presents as a new, painless or changing mole that has increased in size, has changed colour or has started to bleed. Consequently, any skin mole of any concern should be shown to the team doctor.

Melanomas can also form at the back of the eye on the retina, so as well as high-factor sun cream SP50 applied frequently, the use of shirts, hats and importantly sunglasses is recommended where possible in sunnier environments.