What is the best course of treatment for a wrestler with a rash on their right arm that was initially itchy but improved with anti-itch cream, after trying over-the-counter (OTC) antifungal cream?

Treatment of Wrestling-Associated Arm Rash

For a wrestler with a scaly, itchy arm rash that has not responded to OTC antifungal cream, prescribe terbinafine 1% gel once daily for 1 week or continue a different topical antifungal (ciclopirox 0.77% cream twice daily) for 4 weeks, and exclude the wrestler from competition until 10 days of topical treatment is completed. 1, 2

Diagnosis and Clinical Context

This presentation is highly consistent with tinea corporis gladiatorum (wrestling-associated ringworm), which is extremely common in wrestlers and responsible for significant lost training time. 1, 3, 4

• Tinea corporis in wrestlers typically presents as scaly, itchy plaques on exposed areas like the arms, face, and trunk 1
• The most common causative organism in wrestling outbreaks is Trichophyton tonsurans, followed by T. corporis 1, 2
• Itching may persist for weeks even with appropriate treatment due to hypersensitivity reactions and does not indicate treatment failure 1
• The fact that OTC antifungal cream was tried suggests inadequate duration or wrong agent selection 1

Recommended Treatment Approach

First-Line Topical Therapy

Terbinafine 1% gel applied once daily for 1 week is the most effective short-course topical option with approximately 94% mycological cure rate 1

Alternative topical regimens if terbinafine is unavailable: 1

• Ciclopirox olamine 0.77% cream or gel twice daily for 4 weeks (superior to clotrimazole with ~60% cure rate)
• Naftifine ointment twice daily for 4 weeks

When to Use Oral Therapy

Oral antifungal therapy is indicated for: 1, 2

• More than 2 lesions
• Any facial lesions
• Extensive body surface area involvement
• Failed topical therapy after appropriate duration

Oral treatment options: 1

• Terbinafine 250 mg once daily for 1-2 weeks (preferred for T. tonsurans)
• Griseofulvin 500 mg daily for 2-4 weeks (alternative, though less effective for Trichophyton species with only 67.9% response rate) 1
• Itraconazole 100 mg daily for 2 weeks (alternative option) 1

Return-to-Wrestling Criteria

The wrestler must be excluded from all contact until: 1, 2

• 10 days of topical antifungal treatment completed, OR
• 15 days of oral antifungal treatment completed 2
• Lesions should be covered during the exclusion period 1

Critical Prevention Measures

To prevent outbreak spread to teammates: 1

• Examine all sparring partners for similar lesions 1
• Good personal hygiene with daily showers immediately after practice 1
• No sharing of towels, equipment, or clothing 1
• Disinfect wrestling mats daily with freshly prepared bleach solution (1/4 cup bleach per gallon water) for minimum 15 seconds contact time 1
• Wear rubber-soled flip-flops in communal showers 1

Common Pitfalls to Avoid

Do not assume treatment failure based on persistent itching alone - itching can persist for weeks due to hypersensitivity reactions even with successful antifungal therapy 1

Do not use inadequate treatment duration - many OTC antifungals require 4 weeks of twice-daily application, and premature discontinuation leads to recurrence 1

Do not allow return to wrestling prematurely - this is the primary cause of team outbreaks, with up to 75% of team members becoming infected in documented outbreaks 2, 5

Consider prophylactic fluconazole 100 mg daily for 3 days at season onset and repeat at 6 weeks for high-risk teams with recurrent outbreaks, though this requires infectious disease consultation 1