By Richmond M. Castillo and Philip R. Fischer, MD, DTM&H

Mr. Castillo is a medical student at Mayo Medical School, Rochester, MN. Dr. Fischer is Professor of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.

Mr. Castillo and Dr. Fischer report no financial relationships relevant to this field of study.

SYNOPSIS: Among high school and college athletes, skin infections are most common in wrestlers and football players. Bacterial infections predominate. Up to 22% of wrestlers are colonized with methicillin-resistant Staphylococcus aureus sometime during the season.

SOURCE: Ashack KA, Burton KA, Johnson TR, et al. Skin infections among US high school athletes: A national survey. J Am Acad Dermatol 2016;74:679-684.

Skin infections are known to be problematic among some high school athletes, but there had not previously been a broad review of the epidemiology of skin infections across multiple sports. Kurt Ashack and colleagues used skin infection data collected by High School Reporting Information Online (RIO), an Internet-based high school sports injury surveillance system, from fall 2009 through spring 2014. The study determined the epidemiology of skin infections across multiple high school sports. Skin infections accounted for 1.2% of all sports-related injuries/adverse events prompting a missed practice or game. There were 474 skin infections, a rate of 2.2 infections per 100,000 athlete practices/games. Wrestlers accounted for 74% of infections and football players for 18%. Skin infections were most commonly of bacterial origin (61%), followed by tinea (28%) and herpes (5%). Infections occurred most commonly on the head/face (25%), followed by a forearm (13%). Overall, 64% of affected athletes returned to play within six days.


Seven million U.S. high schoolers participate in sports each year. To decrease the risk of infection, there are prevention and education recommendations. For example, the National Federation of State High School Associations implemented a standardized pre-match procedure regarding having either referees performing skin checks or verifying that skin checks have been performed.1 On the other hand, many high school athletic programs have no policies on hand hygiene or restricting participation by athletes with skin infections.2 As noted by Ashack and colleagues, even post-practice showers can reduce infection rates and are commonly used. Understanding the epidemiology of skin infections among high school athletes can lead to awareness and can drive targeted, evidence-based prevention efforts.

There appears to be a seasonality of infections, specifically infections with Staphylococcus aureus. Jiménez-Truque and colleagues found that among a cohort of 377 collegiate athletes, within both contact and non-contact sports, acquisition of S. aureus colonization is highest during summer, especially for football players.3 It is important for infectious disease specialists to be aware of these vacation months as a key time to implement preventive hygiene measures.

More than one-third of Staphylococcus infections in college athletes are due to methicillin-resistant strains (MRSA).3 Of college athletes, 22% of wrestlers and 8% of football players become colonized with MRSA at some point,4 and actual MRSA infection is also more common in wrestlers and football players than in other athletes.5 Decolonization treatment with intra-nasal mupirocin for five to 10 days (with or without oral rifampicin) reduces the risk of subsequent infection by one-third.5

As athletes head back to school this fall, several interventions potentially could prevent participation-limiting skin infections. First, identification of colonization and subsequent decolonization treatment can reduce the risk of subsequent infection. Wrestlers could be targeted since they are at highest risk.4,5 Further study will be needed to guide widespread policy changes. Second, athletes should shower thoroughly after practices and games. Third, pre-play skin inspection, especially of wrestlers, and removal of athletes with active infection can help reduce the spread of infecting microbes to other athletes. 


  1. Sieck B. Pre-match requirements for referees clarified in high school wrestling. National Federation of State High School Associations News, April 27, 2015. Available at: Accessed June 28, 2016.
  2. Pedersen M, Doyle MR, Beste A, et al. Survey of high school athletic programs in Iowa regarding infections and infection prevention policies and practices. Iowa Orthop J 2013;33:107-113.
  3. Jiminez-Troque N, Saye EJ, Soper N, et al. Longitudinal assessment of colonization with Staphylococcus aureus in healthy collegiate athletes.
    J Pediatr Infect Dis Soc 2016;5:105-113.
  4. Karanika S, Kinamon T, Grigoras C, et al. Colonization with methicillin-resistant Staphylococcus aureus and risk of infection among asymptomatic athletes: A systematic review and metaanalysis. Clin Infect Dis 2016;63:195-204.
  5. Braun T, Kahanov L, Dannelly K, et al. CA-MRSA infection incidence and care in high school and intercollegiate athletics. Med Sci Sports Exerc 2016. [Epub ahead of print.]