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Impetigo

by | Sep 5, 2022 | Bacterial Infections, Hygiene, Infectious Diseases, Mat Funk, Skin and Soft Tissue Injuries

Figure 1 Classic appearing impetigo rash with shallow ulcers that have a honey colored crust.

Figure 1 Impetigo

Impetigo

Sep 5, 2022 | Bacterial Infections, Hygiene, Infectious Diseases, Mat Funk, Skin and Soft Tissue Injuries | 1 comment

Written by Anthony Walls, MD

Those who grapple have likely experienced some sort of mat funk either directly or indirectly. Mat funk is a nickname for a myriad of skin conditions that can occur from grappling, and given their different causes and thus different treatments they each deserve to be broken down and explained. Continuing the mat funk series, this month’s post is on impetigo. Here are the quick bullets, but for the deep dive, keep reading.

  • Impetigo is caused by an infection from a bacteria.
  • Impetigo is very contagious but easily treatable and preventable.
  • While impetigo is typically not dangerous, it is one type of many ‘staph infections’ so if untreated can progress to something more dangerous.

Continue Reading: 10min Read

Overview and History

While no large prevalence studies that I know of exist for Jiu-Jitsu, impetigo is by far the most common bacterial skin infection among wrestlers.1,2,3,4 Impetigo is originally a Latin word that translates as ‘skin eruption.’ This makes sense when you see it because most of the time it’s as if the top layer of skin that is affected erupts into a golden honey looking crust (see Figure 1). Impetigo comes from the root impetere in Latin, which means to attack; I personally find this interesting and slightly poetic given the combat sports are so plagued, or attacked, by this infection.
Prior to knowing the various causes, many ‘skin eruptions’ were given the name impetigo hundreds of years ago, but it wasn’t until 1864 when a British dermatologist named William Tilbury Fox became the first to describe epidemics of a particular contagious skin eruption he termed impetigo contagiosa, to distinguish it from the other impetigo rashes of the time.5,6 It seems, as medical science advanced and the causes of the other various skin eruptions were discovered and other names given for specificity, impetigo contagiosa was shortened to impetigo and the name has stuck ever since.
Etiology and Treatment

Impetigo is a skin infection by a bacteria. Most cases are caused by a bacteria called Staphylococcus aureus (see Figure 2). That’s why many will also refer to it as a ‘staph infection.’ That said, one other bacteria can cause it, a type of Streptococcus, but much less often.7 Both of these bacteria are able to infect many places of the body, and similar to ringworm, there are different layers of the skin that can be infected by these bacteria leading to different symptoms and often different treatment regimens for the same causative organisms. With impetigo, the bacteria infects anywhere on the body’s skin but specifically on its very top layer, and this is why most impetigo infections are able to be treated with a topical antibiotic or antiseptic therapy. Oral antibiotics can be used but usually are only necessary when impetigo is very extensive. Impetigo itself, while highly contagious, is not dangerous. That said, when these bacteria cause infection in different locations of the body (see Figure 3 for an example of a cellulitis infection), the story can be quite different; thus why it is very important to get it treated and not let it advance.

Figure 2 Staphylococcus aureus as seen under a light microscope in its typical clusters.

Figure 2 Staphylococcus aureus

Figure 3 Cellulitis of one leg compared to the other without the infection.

Figure 3 Example of a cellulitis infection.

Prevention
If there is one theme that runs through most of the articles on this site, it’s prevention is always better than treatment. It may seem ominous to hear that ‘participation in contact sports’ makes the list of eleven risk factors for staph skin infections.8 But like many other injuries that affect people in combat sports, there is evidence for certain behaviors and interventions that can help prevent impetigo. Many people point the blame and therefore their preventive measures at the gym mats, and while mat hygiene is important and essential in grappling sports, cleaning them after each use is only the tip of the iceberg of good gym hygiene. The reality is if there is even one person that has a contagious skin infection and rolls, it doesn’t matter how clean the mats are or how often they are cleaned.9 There will be a continuous source of infection that will constantly act as ‘patient zero’ for a gym. While it is true that mats and other shared equipment can harbor and possibly spread an infectious organism, evidence shows that staph is more often cultured off of athletes themselves compared to gym equipment like mats, especially when good mat cleaning techniques are employed.10,11 So as far as prevention measures go, I want to encourage first and foremost that if you are concerned about possibly having any skin infection don’t roll, and get it treated. If you are rash free, there is ample evidence in the medical literature that you can help the collective spread of all mat funk by washing/disinfecting your hands just prior to stepping on the mat,11,12 shower immediately after, and wash your gear after use.
Staph Colonization

A brief word on ‘colonization.’ You may have heard that most people carry staph on their body already, living there on the skin not causing an infection (i.e. colonization), and this is true. Studies in athletes show that colonization prevalence at any given time varies from 34-62%, is highest in contact sports, and about 76% of them will be colonized at least once in a two year period.13,14 Once colonized, staph lives on the various places of the skin, especially in the opening of the nostrils to the nose and on finger tips.10,13 What’s more, those who are colonized are at greater risk for developing a skin infection, like impetigo. 13,14

So it’s logical to consider that actively decolonizing individuals of staph would decrease the risk of infection. There is so much to unpack here with regards to the medical literature, but let me summarize it this way. Yes, there are staph decolonization medicines (mostly topical) and washes that can and do decrease the risk for a staph infection occurring. The concern though is that most evidence shows it only works for about one to three months after the decolonization treatment (usually a 5-day course of topical antibiotics and special anti-septic bathing).8,14 And while monthly repetitive decolonization treatments do decrease the risk of infection more long term, they also increase the risk of producing resistant strains of staph (e.g. an even more resistant form of methicillin resistant staphylococcus aureus or MRSA) and they disrupt good bacteria, aka probiotics, on a person’s body.14 So in summary, decolonization is usually only recommended for those who suffer from recurrent staph infections and have ongoing high risk behavior of colonization, like grappling.15

Conclusion

Conclusion
I want to leave you on a more encouraging note. If you get impetigo, or any staph infection, nothing is wrong with you. Most, nearly 80%, of us will have staph living on us even when following great hygiene techniques. And therefore a good amount of us grapplers will likely get a staph infection at least once. I’ve had impetigo, gotten it treated, and got back on the mat as soon as I could. So I encourage you to care for your team by caring for yourself.

References

  1. Agel J, Ransone J, Dick R, Oppliger R, Marshall SW. Descriptive epidemiology of collegiate men’s wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007 Apr-Jun;42(2):303-10. PMID: 17710180
  2. Herzog MM, Fraser MA, Register-Mihalik JK, Kerr ZY. Epidemiology of Skin Infections in Men’s Wrestling: Analysis of 2009-2010 Through 2013-2014 National Collegiate Athletic Association Surveillance Data. J Athl Train. 2017 May;52(5):457-463. doi: 10.4085/1062-6050-52.2.16. Epub 2017 Mar 31. PMID: 28362160
  3. Kordi R, Mansournia MA, Nourian RA, Wallace WA. Cauliflower Ear and Skin Infections among Wrestlers in Tehran. J Sports Sci Med. 2007 Oct 1;6(CSSI-2):39-44. PMID: 24198702
  4. Yard EE, Collins CL, Dick RW, Comstock RD. An epidemiologic comparison of high school and college wrestling injuries. Am J Sports Med. 2008 Jan;36(1):57-64. doi: 10.1177/0363546507307507. Epub 2007 Oct 11. PMID: 17932400.
  5. REED CB. IMPETIGO OR PYODERMATITIS NEONATORUM. Arch Derm Syphilol.1928;18(1):26–36. doi:10.1001/archderm.1928.02380130029002
  6. Fox, William Tilbury. On Impetigo contagiosa, or porrigo. E-version reprinted by the Royal College of Surgeons of England. Accessed https://archive.org/details/b22315834/mode/1up
  7. Demidovich CW, Wittler RR, Ruff ME, Bass JW, Browning WC. Impetigo. Current etiology and comparison of penicillin, erythromycin, and cephalexin therapies. Am J Dis Child. 1990 Dec;144(12):1313-5. doi: 10.1001/archpedi.1990.02150360037015. PMID: 2244610.
  8. Creech CB, Al-Zubeidi DN, Fritz SA. Prevention of Recurrent Staphylococcal Skin Infections. Infect Dis Clin North Am. 2015 Sep;29(3):429-64. doi: 10.1016/j.idc.2015.05.007. PMID: 26311356.
  9. Brancaccio M, Mennitti C, Laneri S, Franco A, De Biasi MG, Cesaro A, Fimiani F, Moscarella E, Gragnano F, Mazzaccara C, Limongelli G, Frisso G, Lombardo B, Pagliuca C, Colicchio R, Salvatore P, Calabrò P, Pero R, Scudiero O. Methicillin-Resistant Staphylococcus aureus: Risk for General Infection and Endocarditis Among Athletes. Antibiotics (Basel). 2020 Jun 18;9(6):332. doi: 10.3390/antibiotics9060332. PMID: 32570705.
  10. Oller AR, Province L, Curless B. Staphylococcus aureus recovery from environmental and human locations in 2 collegiate athletic teams. J Athl Train. 2010 May-Jun;45(3):222-9. doi: 10.4085/1062-6050-45.3.222. PMID: 20446834.
  11. Young LM, Motz VA, Markey ER, Young SC, Beaschler RE. Recommendations for Best Disinfectant Practices to Reduce the Spread of Infection via Wrestling Mats. J Athl Train. 2017 Feb;52(2):82-88. doi: 10.4085/1062-6050-52.1.02. Epub 2017 Jan 16. PMID: 28092165.
  12. Anderson BJ. Effectiveness of body wipes as an adjunct to reducing skin infections in high school wrestlers. Clin J Sport Med. 2012 Sep;22(5):424-9. doi: 10.1097/JSM.0b013e3182592439. PMID: 22695403.
  13. Jiménez-Truque N, Saye EJ, Soper N, Saville BR, Thomsen I, Edwards KM, Creech CB. Longitudinal Assessment of Colonization With Staphylococcus aureus in Healthy Collegiate Athletes. J Pediatric Infect Dis Soc. 2016 Jun;5(2):105-13. doi: 10.1093/jpids/piu108. Epub 2014 Nov 5. PMID: 27199467.
  14. Karanika S, Kinamon T, Grigoras C, Mylonakis E. Colonization With Methicillin-resistant Staphylococcus aureus and Risk for Infection Among Asymptomatic Athletes: A Systematic Review and Metaanalysis. Clin Infect Dis. 2016 Jul 15;63(2):195-204. doi: 10.1093/cid/ciw240. Epub 2016 Apr 18. PMID: 27090988.
  15. Catherine Liu et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children, Clinical Infectious Diseases, Volume 52, Issue 3, 1 February 2011, Pages e18–e55, https://doi.org/10.1093/cid/ciq146
  16. Figure 2 adapted from photo in public domain from the CDC Public Health Image Library, ID #5147, 1984.
  17. Other figures were created by author, patients involved gave full written consent complying with HIPAA guidelines.

1 Comment

  1. JON SERRANO
    JON SERRANO on September 6, 2022 at 4:24 am

    Great article!

    Reply

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