Herpes gladiatorum is a skin infection caused by the herpes simplex virus type 1. Herpes gladiatorum is also known as mat herpes because it is most often found in wrestlers. This virus also causes cold sores, or fever blisters, on the lips. Herpes gladiatorum infections are common in athletes who play contact sports. The skin infection is spread by direct skin-to-skin contact. Sports that involve close contact, such as rugby and wrestling, may spread the infection from one affected athlete to another. Other names for the disease include “wrestlers herpes” or “mat pox” (after wrestling).
Herpes gladiatorum (“mat herpes”) is a skin infection caused by herpes simplex virus type 1 (HSV-1), the same virus that causes cold sores on the lips. HSV-1 infections are very common. In the United States, 30% to 90% of people are exposed to herpes by adulthood, although many people never develop symptoms
Herpes gladiatorum can be successfully treated with systemic antiviral medications, either valacyclovir or acyclovir. In primary infections, the recommended dosing includes valacyclovir 1 mg taken daily for 10–14 days, or acyclovir 200–400 mg taken five times daily for 10–14 days]. Usually a rash or cluster of small blisters develops that can be painful or painless. A fever and swollen lymph glands may be present. The rash generally lasts 10 to 14 days. There may be a later reoccurrence of the rash.
Other Names
- HSV 1
- HSV 2
- Herpes Simplex Virus
- Herpes rugbiorum
- Scrumpox (after rugby football)
- Wrestler’s herpes
- Mat pox (after wrestling)
Pathophysiology
Primary herpes gladiatorum. Note multiple areas of involvement and regional adenopathy.
- General
- Occurs due to cutaneous inoculation with HSV1
- Variable presentation, practitioner unfamiliarity often leads to misdiagnosis
- The face is involved in more than 70% of herpes outbreaks in wrestling
- Outbreaks
- Although up to 30% of high school athletes carry the virus, only 3% are aware
- For this reason, large outbreaks seem to occur for unknown reasons
- Subsequently, there may be lack of proper suspicion when such outbreaks do develop
- Diagnosis
- Often missed by physicians
- One study estimated that the correct diagnosis was made only 10% of the time on initial presentation
Recurrent herpes gladiatorum
- Skin-to-skin contact
- Transmission is almost exclusively from direct skin-to-skin contact.
- Increases risk of traumatic inoculation
- Sports with prolonged skin to skin contact include wrestling, rugby
- Non-contributory
- Training mats and other fomites (need citation)
Causes
- Inoculation
- Transmitted via viral replication in ganglia and spread along sensory nerve tissue
- Multiple dermatomes can be involved, may be bilateral
- There is a 4 to 11 day incubation period
- Prodrome of hyperesthesia and paresthesia follows incubation
- No systemic signs are present at this time
- Rash
- Papulovesicular rash develops within 2 days, appears in clusters
- May coalesce to form plaques with surrounding erythema, edema
- Crusts develop
- Healing begins within 10 days of onset without hyperpigmentation, scarring
- Constitutional symptoms (low-grade fever, chills, malaise, and anorexia, headache, tender regional lymphadenopathy) often accompany primary infection
- Herpes Keratitis
- Herpetic Whitlow
- Sports
- Wrestlers[9]
- Rugby
- Underlying skin conditions
- Eczema
- Cellulitis
- Abscess
- Impetigo
- Herpes Gladiatorum
- Herpes Genitalia
- Tinea (Capitis, Barbae, Corporis)
- Hidradenitis suppurativa
- Pediculosis
- Scabies
- Molluscum contagiosum
- Verrucae (Warts)
Diagnosis
- History
- The face is involved more than 70% of the time (wrestling)
- The rest of the body makes up the remaining 30%
- Primary HG
- Typically presents with systemic symptoms (malaise, low-grade fever, sore throat, lymphadenopathy, headache)
- 1-2 days later, 1-2 mm maculopapular vesicles will coalesce with minimally reddened base
- 90% to 93% of infections will occur within 8 days of exposure[2]
- Lesions typically affect dominant hand, side of head of preferred tie position (wrestling)
- Secondary HG
- Fewer vesicles, outbreaks are shorter, fewer systemic symptoms
- Reoccur, in the same dermatomal or peripheral nerve pattern
- Physical Exam
- Inspect oral mucosa for evidence of gingivostomatitis
- Ophthalmologic exam for ocular herpes presenting as acute, follicular conjunctivitis
- Herpetic Sycosis: lesions seen in a beard distribution from autoinoculation while shaving.
Herpes Gladitorum of the Head, Face and Scalp
Microbiology
- Direct microbiology for HSV 1, HSV 2 recommended
- Examples: Viral culture, HSV polymerase chain reaction
- Culture is often cheaper, PCR is more rapid
- Often confused with other skin infections
- Help distinguish herpes gingivostomatitis and sycosis from other causes of pharyngitis, folliculitis
- Tzank smear is no longer favored due to poor sensitivity, specificity
- Serology
- Limited clinical value due to high rates of positivity, low rates of active disease
- Commonly lags behind clinical infection
- Direct microbiologic testing of active lesions is preferred over serologic testing
Treatment
Treatment
- General treatment principles[11]
- Athletes are treated with oral antivirals, which speeds resolution of symptoms
- Prevents transmission to an exposed opponent
- Antivirals
- Primary Infection
- Valacyclovir: 1000 mg twice daily (or 20 mg/kg 3 times daily for children <20 kg) for 7-10 days
- Recurrent infection
- Valacyclovir: 500 - 1000 mg twice daily for 7 days
- Prophylaxis
- Valacyclovir 500 mg PO daily (if most recent infection >2 years ago)
- Valacyclovir 1 g PO daily (if most recent infection <2 years ago)
- Primary Infection
- Prophylaxis
- Athletes with a history of herpes labialis, herpes genitalia, herpes gladitorum should consider season-long prophylaxis
- Suspend athletic participation
- Athletes must cease all sporting activity when diagnosed and during treatment
- Return to play is decisions should follow established national guidelines
- Antibiotics
- Not indicated unless super imposed infection is suspected
- Note that patients are often treated with antibiotics for a presumed case of folliculitis
Prevention
- Hygiene
- Athletes should shower immediately after practice
- Use their own soap, towels, and razors.
- Towels washed after each use with hot water, detergent
- Skin Hygiene
- Wash hands often
- Do not pick, squeeze skin lesions
- Report any suspicious lesions to coach or athletic trainer
- Equipment
- Practice and competition gear cleaned after each use with soap and water
- Disinfect training mats after use
- Valacyclovir prophylaxis
- Shown to decrease risk of HSV acquisition, prevent recurrence of previous, outbreak
- True in both HSV-seropositive and HSV naïve wrestlers
- At a wrestling camp, daily oral valacyclovir decreased recurrent outbreaks by 89.5%, prevented contraction of the virus[3]
- Recommend starting at least 5 days before the season, camp or tournament
Rehab and Return to Play
Rehabilitation
- Not applicable
Return to Play/ Work
Primary Herpes Zoster Infection
- NCAA Guidelines[12]
- Must have firm, adherent crust at time of participation
- No evidence of secondary bacterial infection
- No new blisters for 72+ hours
- 120+ hours of antiviral therapy
- No systemic symptoms
- May not cover active infections to allow participation
- NFHS[13]
- All lesions scabbed over
- No new lesions for 48+ hours
- 10+ days of antiviral therapy for cutaneous lesions only
- 14+ days of antiviral therapy if systemic symptoms
Secondary Herpes Zoster Infection
- NCAA Guidelines
- Must have firm, adherent crust at time of participation
- No evidence of secondary bacterial infection
- No new blisters for 72+ hours
- 120+ hours of antiviral therapy
- May not cover active infections to allow participation
- NFHS
- All lesions scabbed over
- No new lesions for 48+ hours
- 120+ hours of antiviral therapy
