Beyond Folliculitis: Recognizing Herpes Gladiatorum in Adolescent Athletes

Abstract

A previously healthy 17-year-old adolescent male wrestler presented to the emergency department with right eyelid swelling, worsening pruritic rash on his forehead, headache, and temperature of 100.9°F despite 4 doses of cephalexin. The patient reported sustaining 4 abrasions on his forehead during a wrestling tournament 2 weeks before, but otherwise denied contact with anyone with skin infections. His symptoms began with paresthesia, followed by headache, pruritus, and eruption of the rash. On physical examination, he had pustules spanning his forehead and extending onto his scalp, as well as a confluent area of crusted lesions on his left forehead (Figure). He had crusted lesions along the medial aspect of his right eyelid and left philtrum. He had numerous nonerythematous pustules on his chin and 3 mucosal lesions. Fluorescein examination was negative for dendrites. Ophthalmologic examination revealed no keratitis. Given suspicion for cutaneous herpes, or herpes gladiatorum, the patient was admitted and treated with intravenous acyclovir, and later oral valacyclovir. Herpes simplex virus (HSV) polymerase chain reaction from an unroofed lesion tested positive for HSV 1, confirming the diagnosis. Herpes gladiatorum is caused by HSV 1 and most commonly affects wrestlers and rugby players, who have increased risk of traumatic inoculation from prolonged skin-to-skin contact.1Selling B. Kibrick S. An outbreak of herpes simplex among wrestlers (herpes gladiatorum).N Engl J Med. 1964; 270: 979-982Crossref PubMed Scopus (85) Google Scholar, 2Anderson B.J. The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum.Med Sci Sports Exerc. 2003; 35: 1809-1814Crossref PubMed Scopus (57) Google Scholar The variability of the rash and practitioner unfamiliarity with herpes gladiatorum often leads to misdiagnosis.3Anderson B.J. Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience.Curr Sports Med Rep. 2008; 7: 323-327Crossref PubMed Scopus (25) Google Scholar, 4White W.B. Grant-Kels J.M. Transmission of herpes simplex virus type 1 infection in rugby players.JAMA. 1984; 252: 533-535Crossref PubMed Scopus (49) Google Scholar Patients are frequently treated with a course of antibiotics for presumed folliculitis. Following inoculation, there is a 4- to 11-day incubation period followed by a prodrome of hyperesthesia and paresthesia without systemic signs.3Anderson B.J. Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience.Curr Sports Med Rep. 2008; 7: 323-327Crossref PubMed Scopus (25) Google Scholar, 5Wilson E.K. Deweber K. Berry J.W. Wilckens J.H. Cutaneous infections in wrestlers.Sports Health. 2013; 5: 423-437Crossref PubMed Scopus (17) Google Scholar, 6Belongia E.A. Goodman J.L. Holland E.J. Andres C.W. Homann S.R. Mahanti R.L. et al.An outbreak of herpes gladiatorum at a high-school wrestling camp.N Engl J Med. 1991; 325: 906-910Crossref PubMed Scopus (119) Google Scholar A papulovesicular rash in clusters develops within 2 days. Papules may coalesce to form plaques with surrounding erythema and edema. Crusts develop, followed by healing within 10 days of onset without hyperpigmentation or scarring. Primary infection is accompanied by constitutional symptoms, including low-grade fever, chills, malaise, and anorexia, as well as headache and tender regional lymphadenopathy. In patients with suspected herpes gladiatorum, physical examination must include inspection of the oral mucosa for gingivostomatitis and ophthalmologic examination for primary ocular herpes.5Wilson E.K. Deweber K. Berry J.W. Wilckens J.H. Cutaneous infections in wrestlers.Sports Health. 2013; 5: 423-437Crossref PubMed Scopus (17) Google Scholar Herpetic keratitis often presents as an acute, follicular conjunctivitis, and can lead to scarring and vision loss. On skin examination, herpetic lesions may be seen in the beard distribution. Known as herpetic sycosis, transmission occurs from autoinoculation while shaving. Primary infection should be treated with valacyclovir 1000 mg twice daily (or 20 mg/kg 3 times daily for children <20 kg) for 7-10 days.3Anderson B.J. Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience.Curr Sports Med Rep. 2008; 7: 323-327Crossref PubMed Scopus (25) Google Scholar Recurrent herpes gladiatorum should be treated with valacyclovir 500 mg twice daily for 7 days. Athletes with a history of herpes labialis or gladiatorum should consider season-long prophylaxis with antiviral medication.5Wilson E.K. Deweber K. Berry J.W. Wilckens J.H. Cutaneous infections in wrestlers.Sports Health. 2013; 5: 423-437Crossref PubMed Scopus (17) Google Scholar Players should be suspended from activity, and decisions regarding return to play should follow established national guidelines for high school and collegiate athletes.5Wilson E.K. Deweber K. Berry J.W. Wilckens J.H. Cutaneous infections in wrestlers.Sports Health. 2013; 5: 423-437Crossref PubMed Scopus (17) Google Scholar