A Puzzling Facial Rash on a 17-Year-Old Boy

Faisal M. Mawri, MD; Nida Yousef, MD; Ammar Alhmood, MD; Walid Abuhammour, MD, FAAP, FIDSA


July 09, 2018

The NCAA has developed recommendations on “time until return to competition” for primary herpes gladiatorum and for recurrent infection. For a primary outbreak of herpes, the wrestler must be examined by a clinician or an experienced certified athletic trainer; the following recommendations must be met before a wrestler returns to competition[3]:

  • The athlete must have no signs of systemic symptoms of viral infection.

  • The athlete must be free of any new lesions for 3 days or more prior to the start of competition.

  • Skin lesions must be dry and surmounted by a firm adherent crust.

  • The wrestler must have been on appropriate antiviral therapy for at least 120 hours before the beginning of a competition.

For recurrent herpes gladiatorum, the NCAA has also established several recommendations. First, vesicles must be completely dry and crusted. Second, the wrestler must have been on appropriate dosage of antiviral therapy for 120 hours or more at the time of tournament. For questionable cases, a Tzanck preparation should be performed, and the wrestler's status should be deferred until Tzanck prep or herpes simplex virus assay results are available.[3]

Antiviral drugs with activity against viral DNA synthesis have been effective against PHG infections. Acyclovir, famciclovir, and valacyclovir inhibit virus replication and suppress clinical manifestations, but they are not a cure for PHG because herpes simplex virus remains latent in sensory ganglia. Oral acyclovir has been shown to be effective in suppressing PHG in wrestlers; it is the drug of choice for treating PHG. Acyclovir reduces the duration of symptomatic lesions and is indicated for patients presenting within 2-3 days of the appearance of a herpetic rash. Most patients on acyclovir experience less pain and quicker resolution of their vesicular lesions. Several effective treatments for adult patients include oral acyclovir 200 mg 5 times daily or 400 mg 3 times daily for 7-10 days or until clinical resolution occurs. The recommended dose of acyclovir for PHG in the pediatric age group is 20-30 mg/kg/d, in 5 divided doses, for 7-10 days. As with all infections, prevention is better than treatment.[6]

In addition to the above treatment, wrestlers must practice effective hygiene immediately after wrestling. They must frequently clean competition gear and change towels. Regular hand-washing and thorough cleaning of the mats is critical. Wrestling mats should be cleaned between matches with household bleach (one-quarter cup of bleach in 1 gallon of water). Early identification and treatment can allow the wrestler to return to participation earlier and prevent teammates from contracting the disease. Despite these precautions, PHG spreads during wrestling and other close-contact sports resulting from contact with asymptomatic infected athletes.[2,5]

The patient in this case was started on acyclovir 400 mg 3 times a day for 1 week at the first visit to the pediatric infectious disease clinic. His lesions were likely caused by PHG because the 2 courses of antibiotic treatment that had been initially tried by his primary care provider did not result in improvement. After 1 week of acyclovir, most of his facial lesions were dry and had an adherent crust; however, 2 lesions on his right shoulder remained moist but completely resolved by the second week of treatment. The patient and his parents were advised repeatedly to call and report any eye symptoms, seizure, altered mental status, personality changes, photophobia, or headaches.

On subsequent follow-up, the patient's 13-year-old brother had developed similar lesions; he had borrowed his older brother's headgear, which was the most likely the cause of his lesions. The rash on the brother also resolved after starting acyclovir.


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