What is the appropriate management for an athlete diagnosed with Herpes gladiatorum?

Management of Herpes Gladiatorum in Athletes

Athletes diagnosed with herpes gladiatorum require immediate isolation for 3-8 days with suspension of competition, treatment with valacyclovir 500 mg once or twice daily for 7 days (started within 24 hours of symptom onset), and cannot return to competition until all lesions are fully crusted. 1

Immediate Actions Upon Diagnosis

Diagnostic Confirmation

• Combine clinical recognition with laboratory testing: PCR (most sensitive), direct fluorescent antibody staining, enzyme immunoassay, or viral culture of vesicular lesion scrapings 1, 2
• PCR is 11-71% more sensitive than viral culture and should be used in complex or unclear cases 2
• Type-specific testing differentiates HSV-1 from HSV-2, which has prognostic importance for recurrence risk 2

Isolation Protocol

• Isolate the athlete for 3-8 days during primary outbreaks with complete suspension of competition 1, 2
• This isolation period contains outbreaks in more than 90% of cases when implemented promptly 1, 3
• Screen all teammates and recent opponents for vesicular or ulcerative lesions on exposed body areas, around mouth, and eyes 1

Antiviral Treatment During Active Infection

First-Line Therapy

• Valacyclovir 500 mg orally once or twice daily for 7 days, initiated within 24 hours of symptom onset 1, 2
• This regimen shortens HSV PCR clearance time by 21% (from 8.1 days to 6.4 days) 1
• Critical pitfall: Delayed treatment beyond 24 hours significantly reduces efficacy 2

Alternative Regimens for Active Outbreaks

• Acyclovir 400 mg orally three times daily for 7-10 days 2
• Acyclovir 200 mg orally five times daily for 7-10 days 2
• Famciclovir 250 mg orally three times daily for 7-10 days 2
• Valacyclovir 1 g orally twice daily for 7-10 days 2

Important Safety Consideration

• Advise wrestlers receiving valacyclovir about maintaining good hydration to minimize nephrotoxicity risk 1

Return-to-Competition Criteria

Athletes may return only when BOTH of the following are met:

1. All lesions are completely crusted over (no moist, weeping, or draining lesions) 1, 2
2. Minimum isolation period of 3-8 days completed 1, 2

Alternative pathway: Written physician statement documenting the condition is non-infectious 1, 2

Common Pitfall to Avoid

• Never allow athletes to cover active lesions with dressings and return to competition - this does not prevent transmission 1
• Athletes often deny or fail to recognize infection, requiring vigilant pre-competition screening 1

Prevention of Recurrent Outbreaks

Suppressive Antiviral Therapy

• Athletes with history of recurrent herpes gladiatorum, herpes rugbiorum, or herpes labialis should receive suppressive antiviral therapy 1, 2
• Strong evidence supports nucleoside analogues (valacyclovir) for suppressing recurrent outbreaks 1
• Consider seasonal prophylaxis for HSV-seropositive wrestlers throughout the competitive season 3, 4

Environmental Decontamination

• Clean wrestling mats with freshly prepared bleach solution (1 quarter cup bleach per 1 gallon water) 1
• Apply for minimum 15-second contact time at least daily, preferably between matches 1

Pre-Competition Screening Protocol

• Examine all wrestlers for vesicular or ulcerative lesions on exposed body areas, around mouth, and eyes before every practice and competition 1, 2
• Examiner must be familiar with appearance of HSV, herpes zoster, and impetigo 1
• Exclude any athlete with suspicious lesions until diagnosis is clarified 1

Special Considerations

Transmission Risk

• Herpes can transmit even during asymptomatic periods through viral shedding 2
• Transmission occurs primarily through direct skin-to-skin contact during wrestling 5
• Attack rates vary significantly by practice group, with heavyweights showing highest rates (up to 67%) in documented outbreaks 5

Serious Complications

• Ocular involvement (conjunctivitis, blepharitis, keratitis) can occur, with risk of blindness from acute retinal necrosis 6, 4, 5
• Constitutional symptoms are common: fever (25%), chills (27%), sore throat (40%), headache (22%) 5
• Neurologic complications including paresthesias, weakness, urinary retention, and constipation have been reported 6

Outbreak Management

• Multiple HSV-1 strains can transmit concurrently within different practice groups 5
• Rapid response with 8-day isolation during primary outbreaks prevents epidemic spread 3
• Screen and treat all exposed teammates to contain transmission 3