16. Combined Factors (Pressure, Friction, Occlusion, and Heat)

Friction, Occlusion, and Heat)

The first four chapters in the section on sports-related traumatic skin condi- tions examine the singular effect of friction, pressure, and pounding trauma on the skin, hair, and nails of athletes. This final chapter in the section examines two cutaneous conditions that result from a combination of the forces described in Chapters 12 through 15. Acne mechanica results from a multitude of elements on the skin, including pressure, friction, occlusion, and heat. Pulling boat hands result from the combination of pressure, friction, and a wet and cold environ- ment. Acne keloidalis nuchae likewise develops after exposure to a combination of factors.

Acne Mechanica Epidemiology

There have been no epidemiologic studies of acne mechanica in athletes. A variety of athletes with acne mechanica are reported, including football, tennis, and hockey players, dancers, golfers, shot putters, wrestlers, and weightlifters (Adams, 2001, 2002; Basler, 1992). The joint forces of pressure, occlusion, heat, and friction cause acne mechanica. Some believe that acne mechanica occurs in individuals who already had acne (Mills and Kligman, 1975), whereas others note that a prior history of acne is not necessary for development of acne mechanica (Basler, 1992).

Clinical Presentation

The lesions are well-defined, erythematous papules and pustules distributed in a pattern that relates to the athlete’s causative clothing or equipment (often protective). The most common locations for lesions are the upper back, chin, and posterior scalp (Adams, 2001) (Figure 16-1, see color plate). These loca- tions correlate to the areas of protective equipment used by football and hockey players (Basler, 1992). Helmets help to create the occipital scalp, cheek, and forehead lesions, shoulder pads contribute to the back lesions, and chin straps help to induce the chin and lower cheek lesions.

Tennis players can develop acne mechanica on the upper back, lower neck,

and chest if they wear heavy clothes while practicing in the cold (Basler and

Garcia, 1998). Wrestlers develop acne mechanica beneath their headgear and knee and elbow pads (Adams, 2001, 2002). While walking, golfers acquire lesions on their lower lateral back corresponding to the area where the golf bag rests. Dancers get acne mechanica under their tight-fitting leotards.

Field event athletes, particularly those who throw the shot put, can develop acne mechanica. A shot putter’s technique repetitively places the metal shot on a sweaty neck for hours on end. This method is the perfect recipe for development of acne mechanica. Weightlifters are also at risk to develop acne mechanica. While bench pressing and arching the back for extra support and power, athletes may experience a great deal of pressure and friction on their sweaty upper back. Weightlifters constantly bring the bar-bearing weights to their upper central chest. Not surprising then, acne mechanica occurs on the upper central back and chest in weightlifters (Adams, 2001, 2002) (Figure 16-2 and Table 16-1).

Figure 16-1. Football players frequently develop acne mechanica beneath the

chin strap. This type of acne is much more difficult to treat than typical acne

vulgaris. (See color plate.)

Figure 16-2. Weightlifters may develop acne mechanica on the central chest.

Table 16-1. Location and Cause of Acne Mechanica According to Sport

Sport Acne Location Etiology

Dancing Trunk Tight leotard

Football Chin Chin straps

Shoulders Shoulder pads

Upper inner arm Shoulder pad straps

Forehead, cheeks Helmet

Golf Lower lateral back Golf bag being carried

Hockey Chin Chin straps

Shoulders Shoulder pads

Upper inner arm Shoulder pad straps

Forehead, cheeks Helmet

Shot put Neck Shot put before launch

Tennis Back Heavy warm clothes

Weightlifting Upper back Plastic/vinyl bench cover Upper central chest Weight bar

Wrestling Chin, neck (periauricular) Headgear

Elbows, knees Elbow and knee pads

Diagnosis

The clinician needs to astutely consider an athlete’s equipment and clothing when confronted with acneiform papules. Upon questioning the athlete about sport activities, the sports clinician will be able to make the diagnosis.

Very early lesions of tinea corporis gladiatorum, herpes gladiatorum, and impetigo may closely resemble early lesions of acne mechanica. On these very rare occasions, bacterial, fungal, and viral cultures and a punch biopsy may be necessary.

Treatment

Lesions improve after the season ends and the instigating clothing or equipment is no longer being used. Acne mechanica tends to be more resistant to therapy than typical acne vulgaris. Unless the clinician and athlete address the physical factors causing the acne, this condition will persist.

Topical therapy includes topical retinoids (e.g., tretinoin and tazarotene) and topical antibiotics (e.g., clindamycin solution, gel, or lotion). In my experience, tazarotene is the most effective, although no studies confirm this observation. Benzoyl peroxide products also are helpful. Topical compounds of keratolytics (3% salicylate and 8% resorcinol in 70% ethanol) also have been useful. Some clinicians add clindamycin to that compound (Basler, 1992).

Systemic antibiotics may be effective, but not as effective as for typical acne vulgaris.

Prevention

Prevention of acne mechanica is critical because the treatment regimens are suboptimal. First, athletes should immediately shower after their sports activity.

High school and collegiate athletes with their busy schedules frequently forego showering after practice. Use of mildly abrasive soaps in the areas of acne mechanica while bathing has been suggested (Adams, 2001; Basler, 1992). Ath- letes also can use keratolytic lotions (e.g., salicylic acid or urea cream) after showering to decrease the incidence of acne mechanica.

Athletes can wear synthetic moisture-wicking material beneath shoulder

pads and other protective equipment. This relatively new technologic clothing

decreases the influence of warmth, moisture, and occlusion, factors that are crit-

ical in the pathogenesis of acne mechanica.

Pulling Boat Hands Epidemiology

A case series of 13 rowers/sailors noted a total of 30 episodes of this condition from May to October in 1982 in coastal New England (Toback et al., 1985). Each individual developed the condition while on a 30-foot rowing and sailing vessel called the “pulling boat” for 1 to 3 weeks at a time. The median age was 29 years, and 69% of the affected individuals were female. Individuals on similar boats in Florida have not developed this condition. Other at-risk sports include sailing, rafting, canoeing, crew, and kayaking. The combination of rowing’s mechanical trauma and exposure to nonfreezing wet environments produces vasospasm and vascular injury.

Clinical Presentation

Individuals develop pulling boat hands after 3 days to 2 weeks aboard the pulling boat. Initially, well-defined, 1-mm to 1-cm, erythematous macules, papules, and plaques form on the distal dorsal aspect of the hand and proximal fingers, sparing the metacarpophalangeal joints. Subsequently, vesicles and bullae evolve within the lesions and ultimately become violaceous. More than 90% of subjects complain of pruritus, and 70% have associated burning and pain. Sixty-two percent demonstrate associated Raynaud’s phenomenon. All lesions resolve with scarring after 7 days off the boat.

Diagnosis

The diagnosis can be challenging. Clinicians must remember this condition when watercraft athletes from cold climates present with erythematous papules or vesicles on the hands. Failure to appreciate the role of the sport leads to diagnostic failure. The differential diagnosis includes chilblains, epidermolysis bullosa acquisita, porphyria cutanea tarda, palmoplantar eccrine hidradenitis, irritant or allergic contact dermatitis, lupus erythematosus, photoallergic drug eruptions, and polymorphous light eruption.

Histopathologic examination reveals a superficial and deep perivascular lym-

phocytic infiltrate, subepidermal bullae, extravasated red blood cells, and capil-

lary thromboses. Chilblains most resembles pulling boat hands but does not

show histopathologic evidence of subepidermal blisters.

Treatment

A multitude of treatments, including oral antihistamines, topical steroids, and warm-water soaks, have failed to clear pulling boat hands. The only effec- tive cure has been getting off the boat.

Prevention

Sunscreen does not prevent the condition. Rowers develop more episodes during May than August, which suggests that acclimatization and warmer tem- peratures can prevent pulling boat hands. Waterproof, windproof, and climate control gloves may help to prevent pulling boat hands.

Acne Keloidalis Nuchae Epidemiology

One study investigated the incidence of acne keloidalis nuchae in football players ranging in age from 14 to 27 years. Fourteen percent of African- American football players exhibited the condition. Football players (college age and older) demonstrated more disease (9.4%) than younger players (5.2%) (Knable et al., 1997). Occlusion and friction with the football helmet initiate or exacerbate acne keloidalis.

Clinical Presentation

The athlete occasionally develops multiple, pruritic, grouped, discrete and confluent, erythematous to violaceous papules and plaques on the posterior neck and occipital scalp (Figure 16-3).

Diagnosis

The diagnosis is made based on the morphologic features and distribution.

Treatment

Treatment during the football season can be difficult. During the season, one

National Football League (NFL) football player continued to develop lesions

despite therapy (Harris, 1992). The eruption cleared during the off season. The typical therapeutic modalities include topical and oral antibiotics (e.g., clin- damycin and minocycline, respectively), topical retinoids, intralesional steroids, CO

laser, radiation therapy, and excision. Warm compresses for 10 minutes twice per day may be necessary for draining areas on the posterior neck or occip- ital scalp.

Prevention

Predisposed athletes must avoid very short haircuts on the occipital scalp.

Players can place a thin pad between the scalp and the posterior portion of the helmet.

Bibliography

Adams BB. Sports dermatology. Adoles Clin 2001;12:305–322.

Adams BB. Dermatologic disorders of the athlete. Sports Med 2002;32:309–321.

Basler RSW. Acne mechanica in athletes. Cutis 1992;50:125–128.

Figure 16-3. Athletes may develop many discrete or confluent, erythematous,

violaceous papules and plaques on the back of the scalp, particularly aggravated

by helmets.

Basler RSW, Garcia MA. Acing common skin problems in tennis players. Phys Sportsmed 1998;26:37–44.

Harris H. Acne keloidalis aggravated by football helmets. Cutis 1992;50:154.

Knable AL, Hanke WC, Gonin R. Prevalence of acne keloidalis nuchae in football players.

J Am Acad Dermatol 1997;37:570 –574.

Mills OH, Kligman A. Acne mechanica. Arch Dermatol 1975;111:4813.

Toback AC, Korson R, Krusinski PA. Pulling boat hands: a unique dermatosis from coastal

New England. J Am Acad Dermatol 1985;12:649–655.