Herpes Gladiatorum

By admin Last updated Sep 25, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Herpes Gladiatorum

Luke M. Spellman

Julie M. Kerr

Basics

Description

Variant of cutaneous herpes disease caused by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2) occurring among wrestlers and transmitted by direct skin-to-skin contact

Epidemiology

Affects 2.6% of high school wrestlers and 7.6% of collegiate wrestlers

Risk Factors

Abrasions increase the likelihood of acquiring infection.
Stresses of weight loss, competition, and school responsibilities can lead to recurrence.

General Prevention

Isolate infected wrestler to prevent skin contact with other wrestlers.
Used to control outbreaks among previously infected wrestlers
Acyclovir 200 mg b.i.d.
Valacyclovir 500 mg or 1 g daily
Famciclovir 250 mg b.i.d.
Consider using prophylactic antiviral medications during the wrestling season or before important tournaments.
Teach skin hygiene and protect other skin abrasions from secondary contact with HSV.
Educate athletes to identify lesions/recurrence and seek early treatment in these situations.

Diagnosis

History

Initial vs recurrent eruption
Similar location as previous infection
Previous treatment and length of infection
History of recent stressors (eg, school, sleep, weight loss, emotional)

Physical Exam

Incubation period for primary infection is 2–14 days.
Prodrome of burning, stinging pain, or itching at the infected site, followed by clusters of vesicles on an erythematous base
Common locations include head, neck, and upper body
Symptoms of fever, localized lymphadenopathy, malaise, myalgia, or pharyngitis may accompany infection, especially with 1st episode.
Repeated outbreaks usually are less severe and involve a smaller area.
Infections around the eye increase the risk of corneal or retinal involvement, such as keratoconjunctivitis or retinal necrosis.
Erythema and grouped vesicles, ulcers, or crusts on head, face, neck, or upper extremities most common, but may occur anywhere on the body

Differential Diagnosis

Impetigo
Herpes zoster
Folliculitis
Allergic or contact dermatitis
Tinea gladiatorum
Cellulitis
Think herpes if infection fails to improve after 3–4 days of oral antibiotic therapy and if lesions cross the midline and involve the face and scalp.
Diagnosis can be made by viral culture or Tzanck smear of vesicle fluid.
According to a recent study, polymerase chain reaction testing is a sensitive and cost-effective method to determine viral presence and should be considered the gold standard for detecting HSV-1 or HSV-2 in individuals with a rash suggestive of a herpes infection.

Treatment

Initial infection:
- Started early in the clinical course, during vesicle formation, oral antiviral medications can arrest viral replication and shorten the duration of infection.
- Acyclovir 200 mg 5 times a day or 400 mg 3 times a day for 10 days
- Valacyclovir 1 g b.i.d. for 10 days
- During the ulcer stage, benzoyl peroxide and use of a hair dryer can help dry crusts more rapidly and minimize secondary bacterial infections.

P.305

Recurrent infection:
- Antiviral medications begun during the prodromal phase can effectively shorten the duration of recurrent infections.
- According to a recent study, treatment with 1 g valacyclovir daily reduced herpes gladiatorum (HG) outbreaks by 92% in individuals with a <2-yr history of recurrent HG, and treatment with 300 mg valacyclovir daily reduced HG outbreaks in 88% of those with a longer than 2-yr history of recurrent infection.
- Acyclovir 200 mg 5 times a day for 5 days
- Valacyclovir 500 mg b.i.d. for 5 days
- Famciclovir 125 mg b.i.d. for 5 days
- Valacyclovir 1 g b.i.d.
- Famciclovir 250 mg 3 times daily
- Valacyclovir 2 g × 1 dose; repeat in 12 hr

Additional Reading

Anderson BJ. The effectiveness of valacyclovir in preventing reactivation of herpes gladiatorum in wrestlers. Clin J Sports Med. 1999;9:86–90.

Anderson BJ. Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience. Curr Sports Med Rep. 2008;7:323–327.

Anderson BJ. Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling cAMP. Jpn J Infect Dis. 2006;59:6–9.

Anderson BJ. The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum. Med Sci Sports Exerc. 2003;35:1809–1814.

Annunziato PW, Gershon A. Herpes simplex virus infections. Pediatr Rev. 1996;17:415–423; quiz 424.

Becker TM, Kodsi R, Bailey P, et al. Grappling with herpes: herpes gladiatorum. Am J Sports Med. 1988;16:665–669.

Belongia EA, Goodman JL, Holland EJ, et al. An outbreak of herpes gladiatorum at a high-school wrestling camp. N Engl J Med. 1991;325:906–910.

Dienst WL Jr, Dightman L, Dworkin MS, et al. Pinning down skin infections: diagnosis, treatment, and prevention in wrestlers. Physician Sportsmed. 1997;25:45–50.

Stacey A, Atkins B. Infectious diseases in rugby players: incidence, treatment and prevention. Sports Med. 2000;29:211–220.

Codes

ICD9

054.9 Herpes simplex without mention of complication

Clinical Pearls

Return to play: National Federation of State High School Associations Sports Medicine Advisory Committee guidelines:
- Herpetic lesions (simplex, fever blisters/cold sores, zoster, gladiatorum): To be considered “noncontagious,” all lesions must be scabbed over with no oozing or discharge and no new lesions should have occurred in the preceding 48 hr. For primary (1st episode of HG), wrestlers should be treated and not allowed to compete for a minimum of 10 days. If general body signs and symptoms like fever and swollen lymph nodes are present, that minimum period of treatment should be extended to 14 days. Recurrent outbreaks require a minimum of 120 hr or 5 full days of oral antiviral treatment, again so long as no new lesions have developed and all lesions are scabbed over.
  - NCAA guidelines on Herpes simplex:
    - Primary infection: 1. Wrestler must be free of systemic symptoms of viral infection (fever, malaise, etc.). 2. Wrestler must have developed no new blisters for 72 hr before the examination. 3. Wrestler must have no moist lesions; all lesions must be dried and surmounted by a FIRM ADHERENT CRUST. 4. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hr before and at the time of the meet or tournament. 5. Active herpetic infections shall not be covered to allow participation. See above criteria when making decisions for participation status.
    - Recurrent infection: 1. Blisters must be completely dry and covered by a FIRM ADHERENT CRUST at time of competition, or wrestler shall not participate. 2. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hr before and at the time of the meet or tournament. 3. Active herpetic infections shall not be covered to allow participation. See above criteria when making decisions for participation status.
    - Questionable cases:
      - Tzanck prep and/or HSV antigen assay (if available)
      - Wrestler's status deferred until Tzanck prep and/or HSV assay results complete
Wrestlers with a history of recurrent herpes labialis or herpes gladiatorum could be considered for season-long prophylaxis. This decision should be made after consultation with the team physician.