What is the diagnosis and treatment for a pediatric wrestler with a red, scaly rash on the chin, potentially indicative of a contagious skin infection such as tinea (ringogle) or impetigo?

Red Scaly Rash on Chin of a Child Wrestler: Diagnosis and Management

This is most likely either tinea corporis gladiatorum (ringworm) or impetigo, and you must confirm the diagnosis with potassium hydroxide (KOH) preparation or fungal culture for tinea, or clinical examination for impetigo's characteristic honey-crusted lesions, before initiating treatment and excluding the wrestler from competition. 1

Differential Diagnosis

The two most common contagious skin infections in wrestlers presenting with red, scaly rashes are:

• Tinea corporis gladiatorum (ringworm): Caused predominantly by Trichophyton tonsurans (>80% of cases), presenting as scaly, erythematous patches that may or may not have the classic ring appearance in wrestlers 1
• Impetigo: Highly contagious bacterial infection caused by β-hemolytic Streptococcus spp. and/or S. aureus, characterized by discrete purulent lesions with honey-colored crusts 1

Key distinguishing features:

• Tinea presents with fine scaling, may be pruritic, and requires KOH preparation showing hyphae for confirmation 1
• Impetigo presents with purulent, crusted lesions that are moist or draining, and diagnosis is primarily clinical 1, 2

Immediate Management Steps

If Tinea Corporis Gladiatorum is Confirmed:

Exclude the wrestler from all practice and competition immediately until treatment is complete and lesions have resolved. 1

Treatment approach:

• For limited lesions: Topical antifungal creams (azoles or allylamines) applied twice daily for 2-4 weeks 1
• For extensive or facial lesions (like the chin): Oral antifungals are preferred 1
  • Itraconazole 100 mg once daily for 15 days (87% mycological cure rate, superior to griseofulvin) 1
  • Terbinafine is superior for T. tonsurans infections 1

If Impetigo is Confirmed:

Begin antibiotic therapy immediately and exclude from wrestling for at least 72 hours. 2, 3

Treatment approach:

• For limited lesions: Topical mupirocin 2% ointment applied three times daily for 5-7 days 2, 4, 5
  • FDA-approved with 71% clinical efficacy in impetigo vs. 35% for placebo 5
• For extensive lesions or when topical therapy is impractical: Oral antibiotics 2, 4
  • First-line options: Cephalexin, trimethoprim-sulfamethoxazole (TMP/SMX), or doxycycline based on local MRSA susceptibility patterns 2
  • Consider CA-MRSA coverage if patient is at risk or fails first-line therapy 1

Return-to-Competition Criteria

For Impetigo (All Organizations Agree):

The wrestler must meet ALL of the following criteria before returning: 2

• Completion of at least 72 hours of antibiotic therapy 2, 3
• No new skin lesions for at least 48 hours 2, 3
• No moist or draining lesions at the time of practice or competition 2, 3
• All lesions must have well-adhering scabs (per NFHS guidelines) 2

Critical pitfall to avoid: Active purulent lesions cannot be covered to allow participation—they must be completely resolved 2, 3

For Tinea Corporis:

• Complete resolution of lesions with appropriate antifungal therapy 1
• Confirm mycological cure if possible before return 1

Environmental Decontamination (Essential for Both Conditions)

Clean wrestling mats with freshly prepared household bleach solution (1/4 cup bleach in 1 gallon water) applied for minimum 15 seconds contact time, at least daily and preferably between matches. 1, 3

Additional measures: 2, 3

• Decontaminate all personal items including towels, clothing, and equipment 3
• Avoid sharing equipment or clothing with other wrestlers 1, 3
• Screen all team members for similar lesions to identify outbreak early 2

Common Pitfalls to Avoid

• Allowing early return to competition: Wrestlers are highly motivated to compete and may minimize symptoms; strict adherence to the 72-hour antibiotic rule for impetigo is mandatory 2, 3
• Attempting to cover active lesions: This does not prevent transmission and violates competition rules 2, 3
• Failing to confirm diagnosis: KOH preparation should be performed for suspected tinea, as clinical appearance in wrestlers may be atypical 1, 6
• Inadequate environmental cleaning: Failure to properly disinfect mats and equipment perpetuates outbreaks 1, 2, 3
• Not screening teammates: Up to 24-53% of wrestlers may have tinea corporis during outbreaks, requiring team-wide screening 1

Special Considerations for Wrestling

Wrestling creates a uniquely high-risk environment due to: 1, 2, 7

• Constant skin-to-skin contact during practice and competition 1, 7
• Skin breaks from mat burns that allow pathogen entry 2, 3
• Sharing of equipment and warm, humid environments 1
• Skin infections account for 8.5-20% of all adverse events in young wrestlers 7, 8