Rash on Outside of Right Leg in a 15-Year-Old Wrestler
This is most likely a bacterial skin infection (impetigo, folliculitis, or cellulitis) or herpes gladiatorum, both common in wrestlers due to skin-to-skin contact and shared equipment exposure. 1
Immediate Assessment Priorities
Examine for vesicular or ulcerative lesions first to rule out herpes gladiatorum, which requires immediate isolation from wrestling for 3-8 days to prevent outbreak spread. 1 Look specifically for:
- Grouped vesicles on an erythematous base (classic herpes presentation) 1
- Honey-crusted lesions (impetigo) 1
- Follicular pustules or furuncles (staphylococcal folliculitis/abscess) 1
- Erythema, warmth, and tenderness extending beyond a focal lesion (cellulitis) 1
Check for systemic symptoms including fever, which would indicate more serious infection requiring urgent treatment. 1 Wrestlers with fever and skin infections should not return to competition for at least 24 hours after starting antibiotics. 1
Most Likely Diagnoses in Wrestlers
Herpes Gladiatorum (Wrestling-Associated HSV)
If vesicular lesions are present, this is herpes gladiatorum until proven otherwise. 1 This is the most critical diagnosis to make early because:
- Prompt identification and isolation prevents outbreaks in >90% of cases 1
- Wrestlers must be excluded from competition until all lesions are fully crusted or a physician provides written clearance 1
- Valacyclovir 500 mg twice daily for 7 days (when started within 24 hours of symptom onset) reduces viral clearance time by 21% 1
- Diagnosis can be confirmed with PCR, direct fluorescent antibody, or viral culture of vesicle fluid 1
Staphylococcal/Streptococcal Skin Infections
If honey-crusted lesions, pustules, or abscesses are present, treat for bacterial infection. 1
For localized impetigo (honey-crusted lesions):
For folliculitis, furuncles, or cellulitis:
- Oral first- or second-generation cephalosporin for methicillin-susceptible S. aureus 1
- If MRSA is suspected (based on local prevalence or treatment failure): use trimethoprim-sulfamethoxazole, doxycycline, or clindamycin 1
- Doxycycline is safe in this 15-year-old for durations <2 weeks 1
- Do NOT use trimethoprim-sulfamethoxazole alone for cellulitis due to poor Group A Streptococcus coverage 1
For abscesses: Incision and drainage is essential, with culture to guide antibiotic selection. 1
Tinea Corporis (Ringworm)
If scaly, annular plaques with central clearing are present, consider fungal infection. 1 Common in wrestlers due to mat contact and skin-to-skin transmission. 1
- Topical terbinafine 1% cream daily for 1 week is highly effective (approved for ages ≥12) 1
- Alternative: topical clotrimazole twice daily for 4 weeks 1
- For extensive disease: oral antifungals may be needed 1
Critical Pitfalls to Avoid
Do not allow return to wrestling without proper clearance. 1 This is the most common error leading to team outbreaks:
- Herpes gladiatorum: Exclude until all lesions fully crusted 1
- Bacterial infections: Exclude for at least 24 hours after starting antibiotics 1
- Impetigo: Lesions must be covered or healed before return 1
Do not miss herpes gladiatorum by assuming all wrestler rashes are bacterial. 1 Vesicular lesions require different management and have major outbreak implications. 1
Do not use trimethoprim-sulfamethoxazole monotherapy for cellulitis due to inadequate streptococcal coverage. 1
Prevention Counseling
Emphasize hygiene practices to prevent recurrence and team spread: 1
- Shower immediately after practice/competition 1
- Do not share towels, water bottles, or equipment 1
- Clean wrestling mats daily with diluted bleach solution (1/4 cup bleach per gallon water, 15-second contact time) 1
- Cover any skin breaks or wounds before wrestling 1
For recurrent herpes gladiatorum: Consider suppressive valacyclovir therapy during wrestling season. 1