What is the most common herpes simplex virus infection in wrestlers and what is the recommended first‑line oral antiviral regimen for treatment and prophylaxis in a healthy young athlete?

Herpes Gladiatorum in Wrestlers

Herpes gladiatorum (HSV-1 skin infection) is the most common herpes simplex virus infection in wrestlers, and the first-line treatment is valacyclovir 500 mg twice daily for 7 days, with prophylactic suppressive therapy strongly recommended for athletes with recurrent infections. 1, 2

Epidemiology and Clinical Presentation

Herpes gladiatorum is caused predominantly by HSV-1 (not HSV-2) and represents a significant problem in contact sports, particularly wrestling. 3, 4

• Incidence rates range from 7.6% of college wrestlers to 2.6% of high school wrestlers per season, with outbreak attack rates reaching as high as 34-67% during intensive training camps. 3, 4
• Lesion distribution is characteristic: 73% on the head/face, 42% on extremities, and 28% on trunk—reflecting direct skin-to-skin contact patterns during wrestling. 3
• Constitutional symptoms are common and include fever (25%), chills (27%), sore throat (40%), and headache (22%), distinguishing this from simple cold sores. 3
• Ocular involvement (conjunctivitis, blepharitis) occurs in approximately 8% of cases and requires urgent ophthalmologic evaluation. 3

First-Line Treatment Regimen

For Active Outbreaks (Primary or Recurrent)

Valacyclovir 500 mg orally twice daily for 7 days is the preferred first-line regimen for healthy young athletes. 1, 5

• This regimen shortens HSV PCR clearance time by 21% (from 8.1 days to 6.4 days) when initiated within 24 hours of symptom onset. 1, 5
• The twice-daily dosing provides superior compliance compared to acyclovir's five-times-daily regimen. 5

Alternative regimens (if valacyclovir unavailable): 1

• Acyclovir 400 mg orally three times daily for 7-10 days
• Acyclovir 200 mg orally five times daily for 7-10 days
• Famciclovir 250 mg orally three times daily for 7-10 days

Critical Timing Consideration

Treatment must be initiated within 24 hours of symptom onset to achieve maximum therapeutic benefit—this is the single most important factor in reducing viral shedding duration. 1, 5

Prophylactic Suppressive Therapy

For wrestlers with a history of recurrent herpes gladiatorum, seasonal suppressive antiviral therapy is strongly recommended to prevent outbreaks during the competitive season. 6, 1, 7

• Valacyclovir 500 mg once daily throughout the wrestling season is the standard prophylactic regimen. 1
• This approach reduces recurrent infections, decreases asymptomatic viral shedding (which can transmit infection even without visible lesions), and protects teammates and opponents. 7
• Consider HSV serologic testing to identify seropositive athletes who would benefit from prophylaxis, even if they've never had clinical outbreaks. 7

Return-to-Competition Criteria

Athletes must meet ALL of the following criteria before returning to wrestling: 6, 1

For Primary HSV Infection:

• All systemic symptoms (fever, malaise) completely resolved
• No new lesions for 72 hours before examination
• All existing lesions must be completely dry and covered by firm, adherent crusts (no moist lesions)
• Minimum of 5 days of systemic antiviral therapy completed
• Covering active lesions is NOT allowed—lesions must be fully crusted

For Recurrent HSV Infection:

• Lesions must be completely dry with firm, adherent crusts
• Minimum of 5 days of systemic antiviral therapy completed
• No covering of active lesions permitted

Isolation Period:

• 3-8 days of isolation from competition is required during active outbreaks. 1, 5
• Alternatively, a physician's written statement confirming the condition is non-infectious may allow earlier return. 1

Special Consideration: Ocular Herpes Gladiatorum

If eye involvement is present, combination therapy is mandatory: 5

• Oral valacyclovir 500 mg 2-3 times daily PLUS topical ganciclovir 0.15% gel 3-5 times daily—oral therapy alone is insufficient for corneal disease. 5
• Topical corticosteroids are absolutely contraindicated in active epithelial disease as they potentiate viral replication and worsen infection. 5
• Urgent ophthalmology referral is required with follow-up within 1 week including visual acuity and slit-lamp examination. 5

Prevention Strategies for Teams

Pre-Competition Screening:

• Regular examination of all wrestlers for vesicular or ulcerative lesions before every practice and competition. 1, 2
• Immediate exclusion of any athlete with suspicious lesions until diagnosis is confirmed or excluded. 3

Environmental Decontamination:

• Clean wrestling mats with freshly prepared bleach solution (1/4 cup bleach per gallon of water) with minimum 15-second contact time, at least daily and preferably between matches. 1, 2

Education:

• Wrestlers must understand that herpes can be transmitted during asymptomatic periods through viral shedding, so ongoing precautions are necessary even without visible outbreaks. 1
• Athletes with prior oral HSV infection (cold sores) have lower risk of developing herpes gladiatorum (relative risk 0.25), while exposure to opponents with visible lesions increases risk 9.4-fold. 4

Common Pitfalls to Avoid

1. Never allow athletes to compete with covered active lesions—all major athletic organizations (NCAA, NFHS, NATA) explicitly prohibit this practice. 6

2. Never use topical acyclovir as monotherapy—it is substantially less effective than oral antivirals and should be avoided. 6, 5

3. Never delay antiviral initiation—efficacy drops dramatically if treatment is not started within 24 hours of symptom onset. 1, 5

4. Never overlook prophylaxis in recurrent cases—failure to provide seasonal suppressive therapy puts the entire team at risk during outbreaks. 6, 1, 7

5. Never assume lesions are non-infectious based on appearance alone—viral shedding occurs even during asymptomatic periods, and restriction-endonuclease analysis has identified concurrent transmission of multiple HSV-1 strains within wrestling teams. 1, 3