What is the appropriate treatment for scrum‑pox (herpes simplex virus infection of the face/neck acquired during rugby scrums) in an athlete?

Treatment of Scrum Pox (Herpes Rugbiorum)

Treat scrum pox with systemic oral antiviral therapy using valacyclovir 500 mg twice daily for 7 days, initiated within 24 hours of symptom onset, and immediately exclude the athlete from all rugby activities for a minimum of 5 days while on treatment. 1

Immediate Management Algorithm

1. Confirm Diagnosis and Isolate

• Clinically identify vesicular or ulcerative lesions on face/neck/exposed areas acquired during scrum contact
• Consider PCR testing from vesicular fluid if diagnosis unclear, though clinical recognition is usually sufficient 1
• Immediately remove athlete from practice and competition - isolation for 3-8 days is critical to contain outbreaks in >90% of cases 1

2. Initiate Antiviral Therapy

For Primary Infection:

• Valacyclovir 500 mg twice daily for 7 days (or until clinical resolution)
• Must start within 24 hours of symptom onset for maximum benefit - reduces HSV PCR clearance time by 21% (from ~8.1 to 6.4 days) 1
• Emphasize aggressive hydration to minimize nephrotoxicity risk 1
• Ensure systemic symptoms (fever, malaise) completely resolve 1

For Recurrent Infection:

• Same valacyclovir dosing: 500 mg twice daily for 7 days
• Earlier treatment initiation yields better outcomes

3. Return-to-Play Criteria (Strict Requirements)

The athlete cannot return until ALL of the following are met:

• Minimum 5 days of systemic antiviral therapy completed 1
• No new lesions for 72 hours before examination 1
• All lesions completely dry with firm, adherent crusts (no moist lesions) 1
• All systemic symptoms resolved (fever, malaise, weight loss) 1
• No swollen lymph nodes near affected area 1
• Active lesions cannot be covered - covering is not permitted for return to play 1

Critical Pitfalls to Avoid

Do not allow early return: The 5-day minimum on antivirals is non-negotiable, even if lesions appear healed earlier. This protects both the infected athlete and prevents team outbreaks 1.

Do not permit covering of active lesions: Unlike some bacterial infections, active HSV lesions cannot be covered with dressings for competition - this is explicitly prohibited 1.

Do not miss ocular involvement: Examine eyes carefully - herpetic keratitis can cause permanent vision damage and requires ophthalmology referral 1, 2.

Prevention Strategies for Team Management

Outbreak Control Measures:

• Pre-practice/competition skin checks by trained personnel familiar with HSV appearance 1
• Examine all scrum forwards for vesicular/ulcerative lesions on face, neck, and exposed areas 1
• Clean training equipment with freshly prepared bleach solution (1/4 cup per gallon water) for minimum 15 seconds contact time, daily and between matches 1

Suppressive Therapy for Recurrent Cases:

Athletes with history of recurrent herpes rugbiorum should receive prophylactic valacyclovir for remainder of season 1. Strong evidence supports nucleoside analogues preventing recurrent outbreaks 1.

Special Considerations

Neurological complications: Monitor for paresthesias, weakness, urinary retention, or constipation - these indicate sacral radiculopathy requiring extended treatment 2.

Weight loss and systemic illness: Scrum pox can cause significant constitutional symptoms with 3.6-9.0 kg weight loss - ensure complete resolution before clearance 2.

Team-wide screening: When one case identified, examine all scrum forwards as field-acquired transmission is common in this position 2.

The evidence strongly supports aggressive early treatment and strict return-to-play criteria to prevent the severe complications (recurrent keratitis, neurological involvement) and team outbreaks that characterize this condition 1, 2.