A number of infectious agents can be transmitted through combat sports such as wrestling. The differential diagnosis of skin lesions in wrestlers should focus upon the bacterial, viral, and fungal pathogens associated with infections characteristic of combat sports. For example, skin lesions in wrestlers other than HSV may arise from bacterial pathogens such as S. aureus, viral pathogens such as poxvirus, which causes Molluscum contagiosum, or fungal pathogens such as T. tonsurans.
HG is a great masquerader, and to effectively diagnose an HG outbreak, a clinician needs to understand the pathophysiology and mode of transmission of HSV-1 in the context of the sport of wrestling. Relying upon rapid laboratory tests such as Tzanck smears to identify HSV-1 infection will miss many cases, as fewer than 65% of cases are accurately diagnosed by this method, even in the most experienced hands (12). This leaves the viral culture as the usual option for diagnosis. But prior to obtaining cultures to verify viral presence, a provider should understand the clinical presentation of HG. PCR testing is now a widely available diagnostic tool that has made clinical diagnosis and treatment of HG a much easier process. PCR 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.
With facial involvement, more than 90% of primary HG will develop within 8 d after exposure (9). Primary infection is characterized by localized facial pain, pharyngitis, fever to101.5°F, regional lymphadenopathy, and (finally) the typical vesicular outbreak. Right-sided facial involvement predominates in HG because most wrestlers are right handed (9). Primary outbreaks typically show more extensive involvement compared with recurrent outbreaks. Vesicle formation commonly will be spread out over several dermatomes, possibly affecting both sides of the body. Vesicles of approximately 2 mm in diameter typically are coalesced in clusters ranging from 2 to 3 vesicles to as many as 7 to 10. The affected area initially appears reddened and is firm to touch. The lesions are commonly misdiagnosed as folliculitis with surrounding cellulitis. Critical differences between HG and localized bacterial infections are the extensive regional adenopathy observed in HG and the propensity for these lesions to cross the hairline onto the scalp. Without antiviral medications, outbreaks will usually clear within 10 to 14 d but can take longer.
Recurrent HG usually involves a much smaller, localized area, with the outbreak always occurring on a given side. Sidedness depends on the ganglion in which the virus has established latency. Viral reactivation occurs within the ganglion and spreads along the sensory dermatome associated with that ganglion. During a recurrent outbreak, touching an open vesicle and then touching other parts of the body can lead to auto-inoculation of those areas, but reactivation will only occur within the original ganglion.
Recurrent outbreaks typically last 7 to 10 d without treatment, but can clear sooner with oral antiviral medications. Vesicles may appear dried and inactive after 3 d of antiviral treatment, but it is important to recognize that the individual may still be infectious. In an earlier study, virus was detected by PCR for 6.43 d after initiation of oralantiviral therapy (13). Allowing an athlete to return to competition too soon may risk the spread of HG and jeopardize the safety of other wrestlers.
The MSHSL took the unprecedented step of temporarily suspending wrestling competition and sparring in January of 2007 following an outbreak of HG that developed after a large team tournament held in southern Minnesota at the end of December 2006. Within the next 30 d, the virus spread to 24 athletes on 10 teams. Smaller schools with limited access to local health care providers and more consistent continuity of care were better able to control the outbreaks (14). Once the schools in larger communities developed cases, containment was no longer feasible because of the lack of experience among the large set of available providers in the large communities and the continuous care required from experienced medical providers to ensure early diagnosis and proper treatment. Although the MSHSL guidelines for skin checks and treatment are strictly followed at tournaments and meets held in Minnesota, the guidelines alone are insufficient to prevent disease spread in a situation with a rapidly spreading infection involving multiple teams. The MSHSL officials in consultation with representatives of the Sports Medicine Advisory Committee decided to suspend all competition to stop all exposures to the virus and to allow time for potential individual outbreaks to be confirmed and controlled by antiviral therapy. The state-wide wrestling shutdown was ordered for 8 d based upon earlier studies showing that an 8-d isolation period would be sufficient to contain greater than 90% of the predicted disease spread (9).
During the shutdown period, all wrestlers in the state were prohibited from engaging in direct skin-to-skin contact with other athletes. Coaches and athletic trainers performed daily skin checks, and athletes with suspicious lesions were sent to their health care providers for evaluation, culture, and appropriate treatment. By the end of the 8-d break, the number of infected athletes rose to 54 individuals from 23 teams, consistent with the expectation that infections from earlier exposures would become clinically apparent. Notably, only two additional wrestlers developed HG over the next 3 wk leading up to the state tournament. The two athletes who presented with lesions after the 8-d suspension period were members of teams involved in the outbreak. We hypothesize that they were infected by exposure to infected team members who were noncompliant with oral antiviral medications.
Previous studies of HG outbreaks played an important role in establishing criteria to predict the potential for an outbreak to develop epidemic status and determine how long to suspend wrestling competition and sparing to effectively stop the spread of the virus. Based upon these guidelines, the 2007 outbreak was controlled, and only two new cases emerged after the 8-d shutdown. The 2007 HG numbers are consistent with those reported from the 1999 Minnesota HG outbreak (Fig. 3).
In summary, the state-wide 8-d wrestling suspension successfully prevented transmission of the virus within and between teams. Without this preventative intervention, an estimated 180 athletes could have been infected by the time of the state tournament, instead of the 56 who actually were infected (Fig. 4). Furthermore, many of these athletes would not have been able to participate in the tournament.
TREATMENT AND PREVENTION
Topical antiviral agents are not recommended in the wrestling setting. Although topical antiviral agents may speed healing of HG lesions, the dosing parameters (5 to 7 applications each day) are unreasonable (15,16) and compliance is poor (17). Also, no reproducible studies verify the ability of topical antiviral agents to consistently reduce viral shedding and transmission. This leaves the oral antiviral agents as the treatment of choice. The newest oral antiviral agents, valacyclovir and famciclovir, are prodrugs (a prodrug is metabolized in vivo into the active metabolite) of acyclovir and penciclovir, respectively. The improved bioavailability of these oral prodrugs means that they can be given with once- or twice-daily dosing, leading to better compliance.
In a 2003 study evaluating treatment of recurrent HG based upon PCR data, valacyclovir 500 mg BID cleared an outbreak in 6.43 d compared with 8.14 d with placebo (13). In earlier studies, treatment with oral antiviral medications resulted in wound crusting and apparent clinical healing after 3 d, but PCR data detected active viral shedding for anadditional 3.4 d (13). Present treatment guidelines for recurrent herpes labialis focus upon clinical clearance of the outbreak. To reduce the likelihood of viral transmission to an opponent, treatment regimens for wrestlers with recurrent HG outbreaks must be extended long enough to stop viral shedding (6-7 d), regardless of clinical appearance.
No studies have been performed in patients with primary HG outbreaks, but treatment of primary HSV-1 or HSV-2 infection requires higher dosing of antiviral agents (acyclovir, valacyclovir, or famcicylovir) to suppress effectively and expediently viral shedding. With a primary outbreak, wrestlers should be treated with oral antiviral medications and withheld from competition for a minimum of 10 d. Return to competition should be allowed only if all systemic signs of infection, such as lymphadenopathy, vesicles, or fever, are completely resolved. If any of these signs persist, isolation from other wrestlers should be extended up to 14 d.
Suppressive therapy is critical for prevention of recurrent HG outbreaks in individuals known to be HSV-1-seropositive. In individuals with recurrent genital herpes, prophylactic valacyclovir was shown to be effective in reducing herpes outbreaks (18). Based upon those findings, we evaluated prophylactic valacyclovir treatment in wrestlers who had recurrent HG. Treatment with 1 g valacyclovir daily reduced HG outbreaks by 92% in individuals with a less than 2-yr history of recurrent HG, and treatment with 500 mg valacyclovir QD reduced HG outbreaks in 88%of those with a longer than 2-yr history of recurrent infection (19).
At an annual 28-d high school wrestling camp in Minnesota, HG has been a problem for the past 20 yr. Despite excellent hygienic guidelines, outbreaks still occurred. Serological analyses showed that 29.8% of these campers were HSV-1-seropositive, but only 3% were aware of their status (5). In a closed environment like a wrestling camp, outbreaks can spread rapidly. Prophylactic dosing of oral antiviral medication was recommended for every camp participant, regardless of seroprevalence. Since implementation of this recommendation in 2003, HG outbreaks have decreased by 85% to 90% at the camp, significantly improving the health and safety of the young campers (5). Concerns over the development of drug resistance make the chronic usage of any antimicrobial/antiviral therapy a controversial issue. However, the prevalence of acyclovir resistance in immunocompetent individuals is reported to be only 0.3% (20), whereas the risk of HG transmission is 30% in this group (9). Thus, prophylactic antiviral therapy in wrestling camps has its merits.
An alternative approach would be to perform annual serological testing and offer suppressive therapy to all individuals who are HSV-seropositive. This approach would not only identify infected individuals who are unaware of their infection, but would also indicate which wrestlers are seronegative and thus susceptible to a primary outbreak. With this approach, serological testing would need to be repeated every year for seronegative individuals. Once a wrestler was identified as HSV-seropositive, suppressive therapy would be indicated for that wrestling season and for every wrestling season thereafter.
HG will always be an issue in the sport of wrestling. Following simple guidelines can help control the outbreaks and reduce transmission to susceptible individuals. Protocols for transmission control should focus upon proper hygienic principles, including clean workout gear, washing of the mats, daily skin checks before each practice, and showering immediately after each practice and competition. Withholding any wrestler with a suspicious lesion until HG has been eliminated as the cause of the rash is critical to interrupting the transmission vector of skin-to-skin contact. Annual HSV serological testing of all competing wrestlers should be considered, and suppressive therapy should be offered to HSV-seropositive individuals throughout the season. When a large scale outbreak affecting multiple teams occurs in mid-season, a minimum 8-d suspension of all skin-to-skin wrestling contact is required to interrupt the increase in infections.
The following protocols describe treatment for HG outbreaks and prophylactic treatment:
- Recommended treatment of primary HG is 1 mg oral valacyclovir (Valtrex®; GSK) twice daily for 10-14 d or 200-400 mg oral acyclovir (Zovirax®; GSK) five times daily for 10-14 d. No studies have been performed to determine the appropriate dosing parameters for famciclovir (Famvir®; Novartis).
- For outbreaks of recurrent HG, the recommended treatment is oral valacyclovir 500 mg twice daily for 7 d or oral acyclovir 200-400 mg five times daily for 7 d. No studies have been performed to determine appropriate dosing parameters for famciclovir.
- For suppressive therapy or those who are asymptomatic HSV-1-seropositive individuals, prophylaxis with acyclovir 400 mg twice daily or oral valacyclovir 500-1000 mg daily is recommended for the duration of the wrestling season. For individuals with less than a 2-yr history of HG infection, the higher dose of valacyclovir (1 GM QD) is recommended for suppressive therapy. No studies have been performed to evaluate famciclovir as suppressive therapy in this population.
The author thanks Barbara Rutledge, Ph.D., from Concise Communications, for assistance in manuscript preparation.
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