The most common injuries afflicting the athlete affect the skin. Importantly, sports-related dermatoses are affecting athletes from neophyte to the professional [1,2].
Athletic activity may cause or aggravate skin disorders, which in turn may diminish athletic performance [3,4]. For example, a review of the literature showed that skin infections are more prevalent in top level athletes than in general population, particularly during periods of intensive training [5,6]. The athlete is exposed to a wide spectrum of skin diseases that may or may not be unique to the particular sport or activity . Dermatological problems are related to the athlete's skin type, age, sex, sporting activities, environment, and hereditary factors .
The general types of skin conditions related to athletic activity are vast and include traumatic entities, infections, inflammatory conditions, environmental encounters, and neoplasm [2,9]. The area of sports dermatology is rapidly expanding and new entities are being described regularly [9,10].
Traumatic injuries are vast and include most vivid diagnostic terms; some of them are tennis toe: subungual hematoma , black heel: calcaneal petechiae , turf toe: metatarsophalangeal joint sprains , ping-pong patches: traumatic erythematous patches on forearm and dorsal aspect of hand , athlete's modules: are asymptomatic flesh-colored nodules on the dorsum of the feet, knees, or knuckles , and jogger's nipples: painful fissured, eroded nipples .
Most of the available studies have been tended to concentrate on describing cutaneous manifestations of sports participation and possible suggestions for prevention and treatment without focusing on its frequency [9,17]. Very few studies had examined the actual prevalence of skin diseases in relation to active participation in sports [18,19]. Therefore, this study was designed to determine the actual extent of skin disorders among students of Faculty of Physical Education (college athletes) in Assiut University, Upper Egypt.
Patients and methods
It is a cross-sectional study that was conducted at Faculty of Physical Education during February–June 2009 (second term). The students were receiving training regularly 16 and 18 h/week for 15 weeks/term for first and second academic years, respectively.
Male and female college athletes of first (475 students) and second (496 students) academic years were included. Total coverage of the students were followed to yield 971 students with an 89.9% response rate (873 interviewed students). Their consent to participate was verbally requested. The Ethics Committee of the Assiut University approved the study. Several visits and appointments were arranged to decrease ‘dropout’. Each participant was clinically examined by the dermatologist for any skin problem. A study questionnaire was designed for personal and clinical examination data.
The studied athletes differed in the types of sports that they practiced. First academic year students were practicing volleyball, swimming, racquet, and track sports (all for both sexes) football, wrestling (for male) and rhythmic-gymnastics (for female). Second-year students were practicing handball, hockey, field and self-defense sports (for both sexes), boxing, weight-lifting (for male), tennis, and kinetic expression (for female). The sport types were assigned as contact, indoor, outdoor, and water sports.
Clinical diagnoses were classified into either traumatic, infection, aggravation of preexisting dermatoses, or environmental according to previous studies [9,10].
For data entry and statistical analysis, the Statistical Package of Social Science (version 12) program (IBM Co., New York, New York, USA) was used. Data were expressed as mean±standard deviation and percentages. Chi-square test was used to compare differences in distribution of frequencies among various groups. Fisher's exact test was used to compare frequencies among cells with small numbers. P value of less than 0.05 was considered to be significant.
Demographics of studied athletes
Data were available from 873 students (college athletes): 433 and 440 participants from first and second academic years, respectively. Their age ranged from 17 to 22 years, with mean age of 18.81±0.91 years. Approximately 82.0% (716) of the students were males, and their age ranged from 17 to 22 years with mean age of 18.86±0.93 years. Eighteen percent (157) were females, with a range of age of 17–21 years and mean age of 18.61±0.76 years (Table 1).
Overall prevalence of skin disorders
It was reported that 59.8% of total studied college athletes had one or more skin disorders.
Prevalence of skin disease among female college athletes (66.2%) showed no significant statistical difference in comparison with the studied males (58.4%) (P=0.069) (Table 2).
There was no significant difference between first-year (60.7%) and second-year (58.9%) (P=0.572) year collegiate athletes regarding prevalence of skin disease (Table 2).
Number of skin diseases among affected athletes
College athletes free of skin diseases comprised 40.2% of the total studied group. Among the total affected group (59.8%), those with one skin disease comprised 39.9%, whereas 15.3% presented with two skin diseases and 4.6% had three or more skin diseases (Fig. 1).
Prevalence of traumatic injuries, environmental injuries, and aggravation of preexisting dermatoses
Traumatic injuries had the highest prevalence rate (23.9%) of skin diseases among the studied college athletes. Callus was the most common, with a rate of 11.5%; then friction blister (6.2%) followed by striae distensae (3.1%), tennis toe (2.2%), and corn (1.0%). Black heel (0.8%) and ingrowing nail (0.7%) were less common entities. Other less commonly unusual disorders were turf toe (0.5%) and others such as ping pong patches in two (0.2%), athlete's nodules in two (0.2%), and jogger's nipple in one (0.1%) (Tables 3 and 4).
Striae distensae were significantly higher among women (5.7%) than in men (2.5%) (P=0.035). Friction blisters and striae distensae were significantly higher among studied athletes of first year than those of second year (8.3 vs. 4.1%, P=0.01 and 4.4%).
Aggravation of preexisting dermatoses (9.3%)
Acne mechanica represented the major bulk with a rate of 8.4%. Female athletes showed a significantly higher rate of acne mechanica (14%) versus (7.1%) men (P=0.005). In addition, students of first year had higher rate (12.2%) than second-year students (4.6%) (P=0.029). Other less common diseases were listed.
Its prevalence was 6.9%. Sunburn represents the most common entity (4.5%); the studied athletes did not use any protective sunscreens. Xerosis affected 1.4% of the studied athletes followed by allergic contact dermatitis (0.5%). Sunburn was significantly observed among female athletes (20.4%) than male athletes (1.0%) (P=0.0001) and in students of first year (6.7%) compared with students of second year (2.3%) (P=0.002).
Prevalence of infective skin diseases
Fungal infections (17.2%)
Tinea versicolor was the most common infection (10.1%) followed by pityrosporum folliculitis (5.7%), then T. pedis (2.1%). Other less commonly detected diseases were T. cruris (two cases=0.2%) and T. corporis (one case =0.1%). Pityrosporum folliculitis was significantly higher among female athletes (9.6 vs. 4.9%, P=0.023), whereas T. pedis was significantly higher among second-year athletes (4.3 vs. 0.7%, P=0.007%) (Tables 5 and 6).
Bacterial infections (15.5%)
Pitted keratolysis (13.1%) came at the top of the list of bacterial infections and all diseases. Sycosis vulgaris and boils represented 1.4 and 1.3%, respectively. Pitted keratolysis was significantly higher among male college athletes (P=0.0001) particularly and among second-year athletes (P=0.001).
Warts constituted the main viral disease (5.7%). Common warts of the hand and plantar warts constituted 40 and 60%, respectively. Herpes simplex prevalence was 1.0%. All the cases had facial herpes simplex (mainly labialis) as they exposed to contact trauma during wrestling, boxing, and even water contact in swimming.
Scabies was the only detected parasitic infestation with a low prevalence rate of 1.0%.
Skin disorders are prevalent in athletes and a frequent complaint in sports medicine clinics and athletic training rooms . Results of this study clearly indicated that the prevalence rate of skin disorders was approximately 60% among studied college athletes of Faculty of Physical Education in Assiut University, Upper Egypt.
A survey among American collegiate wrestlers, gymnasts, and swimmers (N=87) revealed that approximately 40% of participants suffered from some type of skin disease . In another survey, Fleischer et al.  reported the prevalence of dermatologic lesions to be as high as 74% of the athletes who participated in 1999 Special Olympic World Summer Games (an international cross-section of persons with special needs).
Thus, the relatively high prevalence of skin diseases (approximately 60%) in this study and the variation between prevalence rates in different surveys could be explained by uneven sample size, dissimilar sport comparison, different survey methods, or an actual increase due to exposure to sport participation with its associated factors.
Nevertheless, sports lend themselves to skin disease in many ways. The constant friction against the skin by various forms of equipment causes lesions, such as calluses, corns, and black heel, to name only a few. Sports also create a good habitat for bacteria and fungus by inducing a state of hyperhidrosis and causing traumatic injuries to the skin, which serve as portals for infection. Finally, athletes (and the general population alike) frequently expose themselves to the elements (sun, cold, water) with gross disregard for their skin's health until after the activity is over [10,21].
In this survey, traumatic injuries comprised a sizeable portion with a prevalence rate of 23.9% and were the commonest prevalent skin disease (i.e., higher than fungal disorders, bacterial, environmental). This may coincide with results obtained by Derya et al.  on 121 licensed athletes from four different sports in the city of Izmir, Turkey. They found that traumatic injuries were also the most common group (60 of 121 of athletes). Callus (11.5%) was the most prevalent traumatic skin disorder in this survey. Nevertheless, calluses are seen in almost every athlete. They develop in locations (often hands and feet) experiencing long-term, repetitive friction . Most calluses are painless and many consider them to be a competitive advantage in sports such as gymnastics, weight lifting, and many racquet sports . However, a large callus can interfere with function and may require treatment .
Friction blisters (6.21%) and striae distensae (3.1%) were the next common traumatic injuries in this study. Blisters are common to all athletes and are often quite painful and debilitating [10,25]. Heymann  reported that friction blisters are the most common complaint of marathon runners, with an incidence of 0.2–39.1% . Blisters result from frictional forces that separate epidermal cells at the level of stratum spinosum. Aggravating factors include moisture, heat, type of socks, ill-fitting shoes, and excessive or unusual exercise early in the training [26,27]. The latter factor could explain the significant higher prevalence of friction blister in college athletes of first academic year versus second year. Striae distensae (stretch marks) results from continuous and progressive stretching of skin that occurs in intense sports, such as weight lifting, body building, football, wrestling, and gymnastics . In this study, the significant higher prevalence of striae distensae among college female athletes and first-year athletes were reported. Even less is known about possible differences between male and female athletes in previous results. However, striae are very common and occur in most adult women, as they readily develop at puberty or during pregnancy . The high prevalence among first-year students could be explained by the fact that they largely participated in football, gymnastics, and wrestling.
Tennis toe (2.21%) was relatively uncommon in this study. Tennis toe refers to subungual hematoma, sometimes preceded by erythema, edema, and a throbbing pain that occurs most commonly in the first and second toe. It is common among racquet sport enthusiasts .
All athletes have an increased risk of cutaneous infections such as fungal, bacterial, and viral infections due to exposure to heat, friction, and contact with others [3,29].
Superficial fungal infections (17.21%) were the most common dermatologic infection in our college athletes. Previous reports showed variable rates (4.3–33%) [19,22]. This variation in rates in different surveys could be explained by variation in sample size, dissimilar sport comparison, different environmental factors, and different survey methods. However, the reason for high prevalence of fungal infection in the athlete is due in part to the predilection for fungi to grow in warm moist environments prevalent on the athlete's skin under occlusive clothing and equipment. In addition, fungal spores in the close quarters of an athletic locker room and shared equipment can promote spreading. Moreover, spread among individuals can occur from direct skin-to-skin contact as well .
T. versicolor (10.1%) was the most prevalent fungal infection in this study, with onset after engagement in sport activities. Some researchers concluded that superficial fungal infection including T. versicolor is one of the most common dermatologic problems among athletes [4,8]. The prevalence in our athletes was higher than that reported in the general population in Rural Assiut, Upper Egypt (with rate of 5.7%) . In addition, Fleischer et al.  detected T. versicolor only in two athletes of 1217 Special Olympic athletes screened in North Carolina. Individual susceptibly, varying methodology, and environmental factors could explain this difference in prevalence rates.
Pityrosporum (Malassezia) folliculitis constituted 5.7% in this study. It is a clinically distinct condition and one of the common fungal infections in athletes . It often occurs in the setting of heat, sweating, and poor hygiene . This could explain the higher prevalence among our female athletes as they wore occlusive leotards of synthetic fabrics for rhythmic gymnastics, swimming, or other forms of exercise.
Among athletes, T. pedis is considered as one of the common cutaneous infection [2,31,32]. By contrast in this survey, T. pedis (2.1%) was less commonly prevalent. This is in agreement with other studies that have not shown an increase in T. pedis in athletes [33,34]. A study of professional Chinese and Brazilian soccer players showed an increase in the prevalence of T. pedis in nonathletes (20.8%, five of 24) relative to Brazilian athletes (15.7%, 13 of 83) and Chinese players (0, 0 of 22) . Another study of professional hockey players did not identify any T. pedis in players on the team . Both studies attributed this decrease in T. pedis to increased health education, the judicious use of sandals in locker rooms, and professional foot care. As the case in our study, the college athletes were provided by health education programs and supervision. Moreover, age is an additional factor; previous studies showed a statistically significant increase in the occurrence of T. pedis with increasing age. The Montreal marathon study reported T. pedis in 2.2% of individuals aged 15–25 years (this is nearly similar to the athletes in this study) and in 42% of individuals aged over 45 years .
Bacterial infections are relatively common in athletes [29,36]. In this study, bacterial skin infections had a prevalence rate of 15.5%. Pitted keratolysis represents 13.1% prevalence rate. Most of our studied athletes were not aware of it. It was highly prevalent among the studied men. This might be due to more exposure to maceration, which is a predisposing factor with moisture, in their practicing sports. This is also the explanation for the significantly higher prevalence among second-year students versus first-year students (sport type variation such as running and other field sports). Although it is a benign disorder and usually asymptomatic, the foot can become superinfected if treatment is not undertaken .
The prevalence rates of sycosis vulgaris and boils were 1.4% and 1.3% in this survey. This is in accordance with results obtained by Derya et al. . These lower rates might be due to the positive effect of regular exercise on immunity [22,37].
Viral infections had a prevalence rate of 6.8% in this survey. Nearly similar result was reported by Derya et al. . They detected viral infections in nine athletes of 121 studied. Human papilloma virus infection is of concern to athletes when it causes warts on the hands and feet [1,38]. In this study, warts were the most common (5.7%). This coincides with the findings of Fleischer et al.  who reported a rate of 5.0% in their survey.
With regard to parasitic infestations, it is unusual for athletes to become infected with parasites [2,17,20]. This is in accordance with these results. Parasitic infestation namely scabies had a rate of 1.0%.
The next two common prevalent skin conditions in this study were aggravating (exacerbating) dermatoses (9.3%) and environmental injuries (6.9%). Many skin conditions in the athlete may worsen with physical activity because of an increase in perspiration, heat, and irritation from equipment [2,9].
The term acne mechanica designates papulopustular eruptions caused by pressure, occlusion, friction, and heat [4,39]. These factors cause maceration, which in association with humidity may exacerbate acne vulgaris or cause its appearance in unusual sites in susceptible patients [39,40]. However, there have been reports of patients without a history of acne vulgaris who have a severe case of acne mechanica .
Acne mechanica is this type of acne that may be noticed in many types of athletes. In this survey, it had a prevalence rate of 8.3%. The studied women significantly suffered from acne mechanica (14%) more than men (7.1%). This could be explained by much exposure to heat and moisture during swimming courses in closed places and from wearing occlusive leotards of synthetic fabrics for rhythmic gymnastics or other forms of exercise. First-year athletes showed statistically significant higher rates (12.2%) versus second-year students (4.6%) in this study. There were no definitive explanations; this might be due to more exposure to humidity and stress. However, it needs further evaluation.
Environmental injuries constituted 6.9% of the dermatoses affecting athletes, with sunburn having a prevalence rate of 4.5% in this study. It was concluded that the most commonly encountered injury is sunburn [4,42]. Factors such as sweating and friction because of physical exercise may increase the photosensitivity of the skin and, thus, the risk of sunburn . This study showed that female athletes (20.4%) and first-year athletes (6.7%) had significantly higher rates of sunburn than male athletes (1.0%) and second-year athletes (2.3%), respectively. Even less is known about possible differences between male and female athletes. However, these differences might be attributed to variations in skin color, time, and duration of sport participation that needs further studies.
Xerosis was detected in 1.4% of the studied athletes in this survey. It is caused by frequent showering and exposure of the skin to drying element as supported by previous findings . Allergic contact dermatitis comprised 0.5% among our studied athletes. Their garment might be the cause besides exposure to heat, trauma, and moisture combined with less well-defined genetically predisposed factors in the athlete's skin .
In conclusion, a variety of dermatoses was commonly prevalent among studied athletes. The major skin problems were traumatic injuries, fungal infections, pitted keratolysis, acne mechanica, warts, and sunburn. Sex and sport type might have a role on distribution of certain disorders. Early prevention, recognition, and treatment of these skin diseases should permit the athlete to continue participation without further disability or reduced performance. Further studies are needed to determine the effect of sport type on skin lesions types and risk factors that affect it among athletes at several universities.
The authors thank the Dean of Faculty of Physical Education, Professor Tarek Abed E.L. Aziz and the staff members for their intense efforts and great help in accomplishing this study.
There is no conflict of interest.
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