This special feature starts a regular column by the Chairman of the Department of Dermatology of the East Avenue Medical Center, Marcellano S. Cruz, M.D., FPDS, FPSVI, FPLS.

What skin disorders do athletes get?   
There are several different sports-related dermatoses which include infections, inflammatory reactions, neoplasms, and environment-related reactions.

What skin disorders affect which particular sport?

Common dermatoses
Sports and physical exercise have become integral to modern life. Although their benefits are plentiful, participation in athletic activities can also be associated with a wide variety of skin problems.

Sports dermatoses can result from mechanical trauma, exposure to environmental and infectious agents and various other factors.

The diagnosis of specific sports dermatoses can at times be challenging and requires familiarity with their characteristic clinical presentations. In this article we highlight some of the common skin problems associated with athletic activities.

Acne mechanica
Commonly referred to as sports-induced acne, acne mechanica is caused by a combination of heat, pressure, occlusion of the skin and repetitive frictional rubbing.

It usually occurs in areas covered by protective gear in contact sports. For instance, football players often have follicular papules, pustules and nodules on the forehead, preauricular areas, chin and shoulders where these touch the helmet and straps.

The equestrian shown in the figure has acne mechanica resulting from contact with her chin strap. Golfers can experience acne mechanica on the lateral back where the strap of their golf bag rubs.

Allergic contact dermatitis caused by substances found in sports equipment (e.g., rubber chemicals such as thiurams, mercaptobenzothiazole and carbamates) needs to be considered in the differential diagnosis of acne mechanica. The former appears more eczematous and pruritic and can be confirmed by specialized patch testing.

Foot blisters
Shearing forces during exercise, compounded by perspiration, can separate the layers of the epidermis and lead to friction blisters, which are often quite painful and debilitating.

New or poorly fitted footwear is a frequent culprit.

Black heel, or tache noir
This black discoloration of the posterolateral aspects of the heel is caused by trauma-induced hemorrhage in an area where blood vessels are minimally protected by the overlying skin.

Black heel is associated with frequent quick starts and stops, motion that is typical of tennis or basketball, but it can also occur in football and other sports.

Black palm, or tache noir, refers to punctate hemorrhages seen in athletes who apply pressure to their hands, such as racquet sports players, weightlifters, gymnasts and golfers. Such lesions must be differentiated from acrolentiginous melanoma.

This can be done by gently paring the superficial skin layers of the affected area with a scalpel blade: the black color can be pared away in black heel or black palm, but the deeper pigment in melanoma usually cannot be removed with this method.

Jogger's toe/tennis toe
Trauma-induced subungual or periungual hemorrhage is common among athletes. When toenails slide forward repetitively, colliding with the front of the shoes, this may lead to hematoma formation, onycholysis and subungual hyperkeratosis.

The black-blue discoloration is frequently observed under the distal nail plate, sparing the proximal nail. Specific mechanical stresses in various sports may lead to different nails being affected. Similar hemorrhages can occur in workers who wear steel-toed shoes or boots.

The differential diagnosis includes subungual melanocytic nevus or malignant melanoma, and biopsy of the nail bed may be warranted, especially if the discoloration is unilateral or extends to the nail fold (known as Hutchinson sign).

Piezogenic pedal papules
These skin-colored or yellowish papules along the lateral plantar surface of the heels may become obvious upon prolonged standing or exercise (the figure on the top left shows papules before exercise; the figure on the lower left, papules after exercise).

They are common among long-distance runners but can occur in non-athletes as well, particularly obese people. Herniation of subcutaneous fat is thought to occur through small tears in the plantar fascia.

The lesions are occasionally painful, and elevation of the feet often provides relief.

Pityrosporum folliculitis
This common fungal infection of athletes is caused by the overgrowth of Pityrosporum orbiculare yeast.

Often misdiagnosed as bacterial folliculitis or acne vulgaris, it presents with erythematous follicular papules or pustules on the upper back, trunk and shoulders. In contrast to acne, these patients often do not have pronounced facial lesions.

Pityrosporum folliculitis often occurs in the setting of heat, sweating and poor hygiene.

Tinea corporis gladiatorum
Heat, moisture, friction and close skin-to-skin contact among athletes in combative sports increases the risk of bacterial (e.g., impetigo, furunculosis), viral (e.g., herpes simplex, warts, molluscum) and fungal (e.g., tinea corporis, cruris, facei, capitis and pedis) infections of the skin.

Superficial tinea infections are very common among wrestlers.

Lesions often occur on the arms, trunk, head and neck, corresponding to the areas of greatest contact between combatants. Infections are mostly transmitted through skin-to-skin contact and can present in outbreaks.

Striae distensae or stretch marks
Intense sports, such as weightlifting, body building, football, wrestling and gymnastics, can result in continuous and progressive stretching of skin, which may lead to stretch marks.

These can also occur during pregnancy, weight gain, rapid growth spurts, anabolic steroid use and as a result of Cushing's disease.

How can an athlete with a sports-related skin problem get proper consultation and treatment?
Contact East Avenue Medical Center, Dermatology Department, telephone numbers 942-8877 and 710-0754 to make an appointment with Dr. Marcellano S. Cruz.  You may also call (0917) 534 5065.

Why should an athlete see a dermatologist for sports-related skin problem?
A dermatologist can give special treatments and specific preventive techniques that allow athletes to continue playing their sports.