The skin is the largest organ of the body and has unique characteristics providing a vital interface between internal and external environments. It has excretory, secretory, absorptive, synthetic, and sensory functions. Just 1 square inch of surface area contains over 3,000,000 cells, 4 yards of nerves, and at least a yard of capillaries. It is selectively permeable, serves as a homeostatic mechanism, and attempts to regulate temperature despite external extremes. It contains the same basic elements as do major organs: connective tissue, blood and lymph vessels, nerves and glands.


Managing Skin Trauma

The skin is the first to suffer in almost all injuries from extrinsic forces. The surface layer of the skin is usually quite tough. The "true" skin just beneath the epidermis is abundant with connective tissue that readily serves as a nest for infection that is easily transported throughout the body by veins and lymphatics. Any abrasion, puncture, or open wound offers a potential site for secondary infection. Thus, managing posttraumatic skin disorders is as much preventive as it is therapeutic.

The common skin injuries treated are contusions, abrasions, and friction injuries. Depending on the degree and chronicity of pressure, friction injuries produce late calluses and early painfully tender blisters, erosions, or fissures. Most friction injuries occur early in the athletic season before the player's skin has had chance to accommodate the stress. Later in the season, subcallus blisters are a concern.

Craig offers the reminder that if all minor infections are recognized and treated during their early stage, healing will be faster, and the risk of cross-infection among a team will be greatly reduced. Thus, immediate attention is required for all blisters and skin infections.

Trauma may induce many types of skin eruptions, and this damage may only be microtrauma from wind, dust, sunshine, etc. Mosquito bites cause hive-like itchy areas, and biting flies and wasps can cause painful stings. People are exposed to numerous environmental bacteria, fungi, viruses, poison plants, parasites, dusts, dyes, temperatures, and chemicals, in addition to dirt, perspiration, scratches, and many allergy-producing substances.


Hygiene

Poor general health, inadequate resistance, and excessive fatigue encourage infection. In addition, many skin disorders and their complications are directly or indirectly associated with poor hygiene and sanitation. This may occur before or during management or be aggravated by poor management and prevention techniques. No skin infection should be considered minor, especially with the grime and sweat intimate with many jobs and sports.

Skin lesions may be caused by a primary infection or superimposed on another disorder. Secondary infection is always a danger to the person afflicted as well as those around him/her. One prerequisite for infection is inadequate resistance. The skin is no exception. The resistance of any tissue may be lowered exteriorly by injurious mechanical, chemical, thermal, or electrical stimuli of sufficient degree. It is also lowered by abnormal or subnormal innervation or circulation, and this may be predisposed by interference with normal transmission and expression of nerve impulses at either horizontal or vertical levels.

Infection is related to many occupational and sports injuries. While posttraumatic care is rarely concerned with the contagious exanthems, it openly addressees several skin diseases of bacterial, viral, mycotic, and parasitic origin. Recurrent infections suggest an underlying systemic disorder or a hostile environment.


Patient Education

The first role of any doctor is that of teacher, and this sometimes requires careful diplomacy. Although "team spirit" and cooperation enhance the workplace and team morale, for instance, it should never lead to the interchange of clothing or equipment. Cross-infection often occurs in athletics by interplayer use of athletic supporters, combs, drinking cups, elastic bandages, hats and helmets, socks, slippers, T-shirts, towels, side-line blankets, and other basic clothing and protective equipment. This practice is not as common in the work setting, but is does occur, especially with indifferent blue-collar workers.

Basic cleanliness principles must be followed. For example, strict hygienic measures must be used with disinfecting mouth protectors. Swimmers must preshower before entering the pool to minimize contamination and cross-infection. They should also reshower if they leave the pool to defecate. Wrestling mats must be kept scrupulously clean (eg, herpes, impetigo). Towels pick up more than perspiration; they gather nose and mouth secretions. Pants, sweatshirts, socks, shorts, and athletic supporters must be laundered frequently in a Clorox-like bath to decrease the chance of infection. Hands should be scrubbed after urination, defecation, and before eating.


Direction of Examination

Four dermatologic cautions should be kept in mind: (1) Don't form an opinion from the history of the case. Note the eruption and all other symptoms, then substantiate it by the history and standard diagnostic protocols. (2) Don't depend upon any one symptom, but let your opinion be guided by the general make-up of the disease as a whole. (3) Don't forget that many conditions of the skin depend on general health disturbances. Therefore, (4) don't forget to conduct a systems review when recording a case history. Keep in mind that skin is usually the first organ to show side effects from drugs and many systemic diseases.

Although the skin is the largest body organ in terms of surface area and the most visible, it is often the most overlooked. This is likely because the skin manifests a complex array of both meaningful and unimportant information. To filter first impressions from fact, examination of the skin should include color, texture, moistness, and lesions, along with evaluating the quality of mucous membranes, hair, and nails. Cutaneous temperature, texture, and moisture have a kinship determined by hormones, nutrition, and environmental exposure and contact. Objective evidence of the effects of scratching may be found during the physical work-up as well as whealing, erythema, excoriation, lichenification, new moles or unusual pigmentation.

Clinical features of a skin disorder typically include color changes, hyperesthesia, itching, eruptions, and rashes. These are often associated with dry skin, scaling, vesicles, follicular plugging, acne, and excessive or diminished sweating. The examiner should pose questions to the date of onset, proneness to spreading, rate of progression, original location, seasonal relationship, environmental exposure to irritants, and associated symptoms.

A noticed change in pigmented nevi may offer an important diagnostic clue. Such change may be an alteration in color, an increase in growth, pain, bleeding, itching and inflammation, or recent development. New moles, the development of a sudden brown or black band in a fingernail or toenail in a Caucasian, or a history of black spots in the mouth suggest metastatic melanoma. While such lesions are not within the realm of posttraumatic care, any physician is expected to recognize them and take appropriate action.


Skin Eruptions and Rashes

The aggregate of various lesions encountered constitutes the objective change of skin diseases and establishes the basis for their recognition. These lesions of objective structural changes are divided into two classes: primary and secondary. See Tables 1 and 2.


Table 1.   Types of Primary Skin Eruptions

Papules	A papule is a rounded or oval hard elevation of the skin, varying in size from a pinhead to a pea. Early, it has a feeling similar to that of fine shot beneath the skin. It is usually reddish when fully developed. Warts and pimples are examples. Papules are the characteristic eruption in the first stage of variola.
Vesicles	A vesicle is a slight circumscribed elevation of the skin containing a clear or opaque fluid or serum. It usually follows the papular stage of an eruption and is found in allergic contact dermatitis, herpes, and the second stage of smallpox.
Pustules	A pustule is an elevation of the skin containing pus, about the size of a vesicle. It often follows the vesicular stage in an eruption. A pustule is produced by suppuration of serum contained in a vesicle, giving it a smoky or cloudy appearance. It is found in impetigo, boils, acne, deep fungus infections, and the third stage of smallpox.
Herpes	A herpic eruption consists of a series of minute vesicles situated upon a red hard base attended by a burning or smarting pain. When occurring on the lips, it is called herpes labialis. When occurring on the nose, it is called herpes nasi; around the ribs, herpes zoster (shingles); and in the genital area, it is known as herpes progenitalis.
Blebs (bullae)	These blister-like eruptions are large elevations of the skin containing a clear or opaque fluid. The large vesicles vary in size from a pea to a goose egg.
Wheals	Wheals (pomphi) are circumscribed areas of cutaneous or subcutaneous edema of a temporary character. They are common in allergic reactions from drugs, insect bites, or an environmental irritant such as sunlight, pressure, heat or cold.
Macules	A macule is an area of discoloration without elevation or depression. It may be any color, shape, or size. Macules that occur in the eruptive fevers are red and slightly elevated above the skin level due to hyperemia. They measure 2--4 mm in diameter, may appear upon any skin surface, and may be distributed sparsely or densely. They are characteristic of measles, freckles, and flat moles.
Nodules	Nodules are solid, usually elevated, lesions of the skin of deep origin which vary in size from a pea to a cherry. A nodule is essentially a small tumor.
Petechiae and ecchymoses	Cutaneous or subcutaneous hemorrhages may occur as small spots called petechiae or in large areas called ecchymoses. They occur as an eruptive sign in cerebrospinal meningitis and dengue and are also commonly found in scurvy, purpura, and hemophilia. They are produced from a lack of motor function being expressed in the minute muscular fibers forming the blood vessel walls, permitting them to relax, fibers to separate, and blood to ooze between the minute fibers.
Erythema and exanthem	This is an evenly distributed redness of the skin due to a cutaneous hyperemia such as seen in erysipelas and the exanthemata. The eruption presents an uneven redness.
Telangiectasia	This condition is the result of dilated superficial blood vessels. Most lesions are of unknown cause, but they may be associated with certain systemic disorders (eg, iatrogenic).
Abscesses	An abscess is a collection of pus circumscribed by a pyogenic membrane and located in the subcutaneous tissue. Abscesses of the skin usually develop suddenly and are small in size except when on the scalp. They form round swellings that are hard or firm at first, but soon become soft and fluctuate under pressure. When opened, they give off a thick pus. They are most common on the scalp with eczema, on the face and neck with acne, and on the extremities with scabies. They may disappear by absorption or open of their own accord. There is but slight pain and discomfort in cutaneous abscesses. They differ from a boil in that they are not raised and pointed, do not have a central core, and are less firm. They differ from carbuncles by the absence of constitutional symptoms, brawny infiltration, intense inflammation, and cubiform mode of opening. An abscess differs from syphilitic gumma in that a gumma has no pain, is dark red in color, grows slowly, is usually multiple, and when cut, it gives off little bloody fluid.
Furuncles	Boils may be classed as a form of cutaneous eruption. They are circumscribed areas of suppuration in the subcutaneous tissue and usually involve one or more sebaceous glands. At the onset, they are red; but as soon as suppuration has occurred, they become yellowish-white.
Tumors	Tumors are atypical growths of various size, shape, and consistency located in the deep layers of the skin.

Table 2.   Types of Secondary Skin Eruptions

Cicatrix	This is a scar or a similar effect of nature to heal skin damage by means of connective tissue. It occurs only where the papillary layer of the skin is destroyed.
Lichenification	This term refers to a thickening of the skin associated with accentuated skin markings.
Crust (Scab)	A scab is a dried secretion or exudate (eg, blood, pus, serum) upon the skin which follows vesicles, pustules, weeping eczema, other inflammatory and infectious diseases, cuts and abrasions.
Scale	This is a circumscribed, light in color, thin layer of epidermal cells that has become detached and is about to shed. Scales are common in psoriasis, superficial fungus infections, and chronic dermatitis.
Excoriation	Excoriation refers to a scratch mark or a superficial denudation of the skin.
Fissure	A fissure is a crack in the skin extending down to the corium and usually located in the folds of the skin over the joints.
Erosion	The term erosion refers to a loss of epidermal tissue such as seen in herpes infection.
Ulcer	An ulcer is a deep erosion where epidermal tissue and at least part of the dermal tissue is lost. Ulcers often result from acute bacterial infection, physical trauma, peripheral vascular disease, and chronic fungal infections.

A history or appearance of a rash is often the first clue of a primary dermatologic disease, of a serious systemic disease, of a common infectious process, or of a serious drug reaction. The word "rash" is a vague term. When a rash is a part of the clinical profile, questions should probe onset, first location and changes, initial appearance and changes, relationship to clothing or environmental exposure, relationship to known allergies, family history, personal habits, relationship to cosmetics, prescribed drugs, and proprietary medications. Associated symptoms such as tenderness, deep pain, fever, malaise, joint complaints, itching, oozing, or the formation of hives, blisters, and blebs should be questioned.


Surface Sensitivity

Tenderness is often the result of inflammation and edema. The lack of pain or its diminished perception is also an important clue. Both diseases of cutaneous nerve proper and diseases involving neurovascular bundles in the skin can produce anesthesia. In evaluating the pathophysiology involved, remember that the peripheral paths are involved in the transmission of pain, touch, hot, cold, baragnosis, vibration, and itching.


Itching

Pruritus is a disagreeable cutaneous dysesthesia that demands attempted relief through arbitrary or compulsive scratching. Itching is a type of pain associated only with the skin caused by such a variety of conditions that its presence has little diagnostic value in itself. When severe and continual for weeks on end, it can preoccupy the mind and torment the soul. Both depression and anxiety states may be a contributing cause or an effect. When pruritus is a complaint, note if the itching disturbs sleep, if scratching can be controlled, or what situations appear to aggravate or ease the itching such as certain clothing, events, temperatures, soaps, environments, etc. Very hot showers remove skin oils, encourage microcracks, and enhance itching.

Pruritus can be related to a systemic disease, a primary skin disease, or neither. It may be generalized with or without skin eruptions, or it may be localized with or without evident pathology. Intense itching is associated with poison ivy and oak, and a large variety of allergic, inflammatory, and idiopathic skin conditions. It is also a major feature of obstructive hepatobiliary disease.

Isolated pruritus associated without evident local pathology is characteristic of dry skin, a parasitic infestation, a fungus or mold, a contact sensitivity, a systemic condition, or of psychogenic origin. A severe generalized pruritus may be the result of disease and (1) occur without skin lesions from dry or dirty skin, contact sensitivity, allergies to foods or drugs or soaps, psychogenic factors, metabolic disorders, and malignant conditions; or (2) occur with skin eruption such as with urticaria, contact dermatitis, atopic dermatitis, neurodermatitis, dermatitis herpetiformis, scabies, and lichen planus.

As vasodilation commonly aggravates itching, a patient may report that heat increases (eg, hot shower) and cold decreases pruritus. This effect of vasodilation, however, may be hidden by the sedation effect of warmth.

In mild cases, applications of sesame seed oil are beneficial. It readily absorbs and has mild antibacterial and antifungal properties. Cortisone ointments and lotions are antipruritic but no better than sesame seed oil.


Infection

Before infection takes place: (1) The invading organisms must be pathogenic. (2) They must be present in large numbers. (3) They must possess a sufficient degree of virulence. (4) They must enter the body by a path or avenue adapted to their requirements. (5) They must find an environment suitable to their nutritional requirements. (6) There must be inadequate tissue resistance.

Etiology.   The presence of pathogens in the body does not constitute infection, nor does it indicate the existence of an infectious disease. Various types of bacteria are found in many organs of the body in perfectly healthy people. For example, colon bacilli are found in the intestines; streptococci, staphylococci, and pneumococci are commonly found in the mouth and throat without the existence of symptoms. Pernicious viruses are frequently demonstrated in the stools of the healthy.

Pathogens multiply where they find a suitable environment for growth and development. When there is interference with nerve transmission or circulation, there is disturbed metabolism in the tissue supplied. This reduces cellular activity and permits the accumulation of metabolic waste, furnishing an adequate environment for the propagation.

Bacteria assimilate, reproduce, and excrete. Exotoxin is discharged as excreta from the organism into the culture medium. When the bacterium dies and undergoes disintegration, it gives off poisonous endotoxin. These toxins are injurious to the host and become an etiologic factor in disease, not because their purpose is to cause disease, but because inadequate tissue resistance has permitted the bacteria to establish a domicile in the body.

Antibiotics

Antibiotics frequently reduce the severity and effects of many bacterial disease processes, yet they have distinct disadvantages and many limitations. As life saving as they may be in some cases, they are far from the panacea once claimed. Their widespread use tends to develop new resistant strains of bacteria, to destroy normal intestinal bacteria, and to encourage inactive intestinal fungi to become active. Antibiotics have no effect on viral illnesses such as hepatitis, influenza, or the common cold. They commonly result in side effects, producing symptoms of dizziness, rash, and iatrogenic allergies. Indiscriminate use frequently creates a sensitivity that prohibits the person from later use that might be beneficial.


Wet Dressings

Moist dressings are commonly used in aid stations. They are helpful in maintaining constant lesion drainage, cleansing skin injuries, maintaining a constant site temperature, softening and removing crusts, opening blisters without lancing, and allowing medications to penetrate deeper into infected areas. Room-temperature wet packs tend to produce a soothing anesthetic effect.

Application.   Cleanse irritated skin by washing with a cleansing spray, but avoid vigorous applications of green soap. The typical dressing is made from cheesecloth as absorbent cotton hardens when wet, dries quickly, and becomes an irritant. An antibacterial jelly should be applied to the skin near the area being treated to prevent maceration of allied tissues. The dressing is dipped in distilled water or a medicinal solution, wrung, and then applied to the skin when still wet but not dripping. Any tap water used in a wet dressing should be first boiled or be distilled. Necessary ointments should be applied abundantly.

The wet dressing is overlaid with plastic sheeting to retard evaporation and then covered with a light elastic bandage for security. For an ambulatory patient, warm clothing should be worn over the bandage to prevent chilling. The dressing should never be allowed to become dry. Trying to add water to the ends of the pack will never suffice. The dressing must be completely reapplied periodically. If topical medications are used, the site must be carefully watched the first 24 hours to monitor reaction. This may require a wet pack without a secured protective covering.

Contraindications.   Wet dressings are contraindicated in any condition where circulation is seriously impaired or where the skin becomes drawn or begins to crack. They are usually contraindicated in the elderly because of potential circulatory insufficiences. Classic adhesive tape should never be applied near a moist lesion, area of infection, or suppurative lesion as later removal will insult the lesion. The newer tapes are a blessing. Care must be taken when the dressing is secured that no "tourniquet" effect results. A penicillin ointment should never be applied unless it is known beforehand that the patient in nonallergic. Tar preparations (eg, ichthtol, pragmatar) are contraindicated in skin areas exhibiting heavy hair growth as they tend to produce pustules.

Contusions

Pain, discoloration, and swelling are common to all forms of contusions, but these signs vary in line with the nature of the violence, the site of trauma, and the susceptibility of the individual. Personal performance is affected according to the degree of associated pain, swelling, tissue disorganization, itching, and psychic factors (eg, anxiety, fear).

Posttraumatic swelling varies in degree from a slight puffiness to that of a large hematoma. Hirata refers to the closed soft-tissue swelling associated with contusions as the most frequent problem seen in contact sports. The greater the vascularity of the tissue involved (as in the well-developed athlete), the greater the swelling. Thus, the degree of injury cannot be determined by the quantity of swelling alone.

Management.   Treatment is directed toward relief of pain, restoration of function, and prevention of residual defects. Retard bleeding by cold, moderate compression, elevation, and rest. After 36--72 hours, mild local warmth and adjacent (never direct) vibromassage may be used to alleviate local tenderness, but it is usually not necessary. Activity can be slowly increased to tolerance, then increased gradually to the demands of one's work or the sport. The site should be protected with padding during healing and somewhat beyond to prevent further injury.

Abrasions

Friction abrasions are common in almost all sports and many occupations. The skin is removed, leaving a weeping, extremely tender base that is readily subject to infection. The word "abrasion" means a rubbing, planing, or scrapping of skin or mucous membrane. Turf sports and track events often present abrasions highly contaminated with debris. Abrasions are called "strawberries" in baseball and "floor burns" in basketball.

Management.   Most trainers gently but thoroughly clean the site with a liquid detergent surgical soap, and follow this with a topical ointment having an antibiotic effect (eg, polymyxin B). Penicillin or tetracycline ointments are usually avoided because of the possibility of producing sensitization or hindering future needs. Slightly implanted foreign bodies should be sought and gently removed under local anesthesia if necessary. Most can be "teased out" with the point of a sterile needle until they can be grasped with tweezers.

Warm wet compresses are routine for mildly infected abrasions. Dressings should be changed at least daily after showering. After healing, the site should be protected for 1--2 weeks until it reaches its normal degree of "toughness." Except in the most severe cases, return to activity can be immediate if adequate protection is provided.

Blisters

Blisters form from localized friction with pressure. Tape, loose protection, heat, and prolonged sweating also contribute to blister formation. Before development, a "hot spot" may be perceived at the site of irritation. Then an accumulation of serum arises between intradermal stratum after friction has separated the layers. The associated pain varies with intensity, often inhibiting performance in a given activity by producing a "favoring" away from the irritation. This can predispose sprains and strains through changes in normal biomechanical reactions.

Causes.   Friction blisters are common on the hands and fingers of unconditioned manual laborers such as construction workers, farmers, and gardeners. In sports, they are most prevalent in rowing; racket, stick, club, and fencing sports; and bowling. They arise on the feet in all running sports. The cause for blister formation can often be traced to a lack of work gloves, new or poorly fitted shoes, handtool or racket slippage, quick stops and turns, sock seams, and wrinkled socks. New shoes should be worn a few weeks before use during demanding activity.

Management.   Whether to puncture a blister or not depends on the blister's size, location, and degree of inflammation involved. Most trainers advocate sterile aspiration or puncturing the blister at its base with the point of a sterile scalpel or needle parallel to the skin's surface after the area has been sterilized. The area is then greased with a medicinal jelly and covered with a light pressure pad that won't "mat" during activity. Aspiration is initially effective, but fluid accumulation can return rapidly.

Some trainers recommend covering foot blisters with a soft sterile dressing over a Telfa sheet dressing. Many team doctors advise the use of Neosporin powder for foot blisters. Without proper care, infection can promote a mild irritation into a distinct disability with serious complications.

Williams/Sperryn feel that the quickest way to handle frank blisters in athletics is to thoroughly clean the area, immediately de-roof the blister in a sterile manner, and let it dry in the open air with frequent alcohol douches. While this method is more painful, it assures the most rapid return to competition because it avoids the irritating layers of lint and friction between equipment--dressing--lesion.

Hirata, on the other hand, points out that this method removes the blister's protective outer layer and exposes the easily abraded thin inner layer, equivalent to that of a third degree burn, and encourages secondary infection. He prefers that the blister be opened widely but with the outer skin hinged so that it may be used as a natural inner dressing for protection against abrasion. When the inner layer thickens in 2--4 days, the flap drops off spontaneously. During this process, the site is greased with an appropriate ointment or jelly and covered by a pressure pad to assist drainage and inhibit infection. Subcallus blisters can be treated in the same manner.

Preventing and Treating Foot Blisters.   Painting weight-bearing portions of the soles can reduce sensitivity to foot blister development with oil, silicone, or powder. Athletes who wear wool socks should be advised to wear cotton or silk stockings next to the skin to reduce blister development. It is also helpful to have the player reverse sweat socks so that the seams are away from the skin. Tincture of benzoin should rarely be used as a "protective pad" because it makes the feet "sticky" and increases friction. Greasing the entire foot with a lanolin ointment is both a preventive practice and an aid to healing, but it quickly destroys athletic socks.

Troublesome Callosities

Skin callosities are localized areas of hyperplasia of the horny layer of the epidermis. Formation is a natural attempt to compensate (toughen) the area against trauma; it is a response to chronic irritation. Plantar callosities, probably more than any other type, can become disabling in track when they produce a subcallus blister.

Divers have a special problem from board friction. This occurs because the constant immersion in pool water and showers leaches natural skin oils from the keratinized plaque. This causes the area to dry, crack, and split, often to the degree of bleeding and secondary infection.

Management.   Regular use of a callus file and frequent greasing with a lanolin-base ointment is recommended as a palliative measure. Pool work must be restricted until all signs of infection have subsided.

Subcallus Blisters.   Once a callus becomes thick, it by itself can become a chronic irritant as a keratinized plaque and produce a subcallus blister in deeper tissues. Once developed, treatment is the same as a superficial blister. Prevention is accomplished by having the patient periodically use a fine emery board (ie, callus file) to prevent undue callus build up.

Corns

Corns are round or cone-shaped localized skin callosities that have a horny core. There is a circumscribed area of hypertrophied skin resembling a small shell containing a harder core that may press on nerves of the foot during weight bearing. The cause can usually be attributed to atypical bone formation or position (frequently requiring adjustment), to undue external pressure, or to repeated trauma. There are two types: soft corns and hard corns.

Prevention.   Prevention is aided by keeping the feet clean and dry, wearing round-toed shoes with metatarsal crescents, wearing silk or thin cotton undersocks, having subluxated-fixated bones of the feet adjusted, and performing exercises to strengthen the metatarsal arch.

Management of Soft Corns.   Soft corns form where skin touches skin (eg, between the toes) and where heat is poorly released, perspiration has difficulty in evaporating, and an adjacent bone applies pressure on the skin. First aid consists of the above preventive measures plus using an alcohol foot wash frequently, drying thoroughly, and applying a foot powder. Another method used by many trainers is to dust between the toes with sulfomerthiolate or bismuth formic iodide. Lamb's wool placed between the toes will help keep the area dry.

Management of Hard Corns.   Hard corns are firm, rigid, and dense. They arise over prominent protuberances on parts of the foot where shoes exert considerable pressure such as the lateral side of the small toe and the top of the middle toes. A first-aid measure is to eliminate pressure on the area with pads, rings, of a half-size larger shoe{s), and frequently cover the corn with an effective "corn paint." Stubborn or complicated cases should be referred to a podiatrist.

Surfer's Nodes

Hyperkeratotic skin nodules may develop anteriorly over the tibial tubercles and at the bottom of the feet under the metatarsophalangeal joints. These findings are usually associated with a swollen bursa at the proximal aspect of the dorsum of the foot that develops in the synovial sheath of the extensor digitorum longus tendon. The lesions often result from stressful kneeling on a surfboard. They are often considered a status symbol among uncomplaining surfers.


Lacerations

A laceration is any torn, ragged, mangled, or stabbed wound. Puncture wounds may be minor or serious. The chief dangers in minor wounds are (1) the formation of a thrombus and possible release of clot or fat emboli, and (2) a portal for infection. It is suggested that readers review the control of bleeding and hemorrhage.

Temporary Small Wound Closure.   The following technique is used for closure of a small, shallow incision when gaping is minimal and skin edges can be apposed without difficulty. Two types of sutureless closures may be used --a commercially packaged sterile strip or an improvised butterfly adhesive closure.

1. Sterile skin-closure strip.   These strips are of porous nonirritating material. The adhesive surface is applied directly to the wound. Usually, 1/2-inch-wide 4-inch-long strips are packaged in a peel-back plastic or paper enclosure. In an office setting, the strips are handled with sterile gloves to bring the skin edges together. One or more strips are used for closure. A dry sterile dressing is applied over the strips and secured with a bandage.

2. Butterfly adhesive closure.   A butterfly adhesive closure can be made from an ordinary 1-inch-wide 4-inch-long adhesive strip. It provides less exact skin closure than a commercially prepared sterile strip, but it is often useful as a temporary improvised measure. A sterile dry dressing may be applied over the butterfly strip for protection, but the surface of the strip is not sterile.

Dangers of Coagulants.   The use of "blood-stoppers" in sports, especially by unqualified "cut men," has been a nasty part of athletics for many years. In boxing especially, as the cut-man has just 45 seconds to stop bleeding during a large-purse bout, noxious chemical preparations are often applied:

• Monsel's solution quickly sears torn blood vessels shut when swabbed or powdered into a wound. A thick, black, hard mass of scar tissue results that must be removed surgically. If the solution accidentally enters a fighter's eye, permanent blindness can occur.

• Negatan is a cauterizing drug containing formaldehyde that turns the skin into "leather" in seconds. Many boxing cuts appear in the temporal and supraorbital area of the head, and if Negatan enters a fighter's eye or an opponent's eye, the cornea may become permanently scarred.

• Adrenaline is sometimes used to restrict bleeding blood vessels. Side effects can include increased heart rate and hypertension that can later cause the vessels to rupture. The dangers of using adrenaline, however, are far less than those of Monsel's solution, Negatan, or their substitutes.

Nummular Eczema

This disorder is often induced by the trauma of winter temperatures. It is sometimes seen in sports played outdoors in cold weather such as football, and is most common in linemen who play without gloves or warm socks. It usually begins as a mild itchy skin infection of the hand. Major features are coin-shaped patches of vesicles and papules that progress to a widespread secondary dermatitis characterized by oozing and crust formation, especially during cold weather. The lesions are commonly sited on the extensor aspects of the extremities and on the buttocks. First-aid management emphasizes wet dressings applied during the acute stage; appropriate pastes and ointments used during the chronic stage.


Frostbite

Frostbite (dermatitis congelationis) is a form of localized tissue destruction from freezing where ice crystals form in the skin or deeper tissues. It is a danger once skin temperature falls below 32° F. Other factors include contact with cold equipment, severe local vasoconstriction, and high airspeed or altitude. Frostbite may be classified by three common stages according to the severity (depth of involvement) of the injury: first degree (erythema); second degree (vesication); and third degree (necrosis).

Areas affected initially are body protuberances such as the ears, nose, fingers, heels and toes. The genitals, cheeks, chin, and female breasts may also be affected. Moist cold, more than dry cold, is a common causative agent. Once clothing becomes soaked with moisture (sweat, snow, slush, rain), the insulation factor is destroyed. This issue along with reduced metabolic activity encourages systemic hypothermia and local areas of frostbite, often occurring during rest intervals between winter sports events.

Clinical Features.   First-degree frostbite features a circumscribed inflammatory skin swelling. The coldness initiates a primary contraction of cutaneous blood vessels resulting in pallor. In response, the vessels dilate and the area reddens and swells, producing a burning pain. White blood cells disintegrate and liberate a coagulating substance, encouraging thrombosis in peripheral vessels. This impairs circulation and produces spastic ischemia. Symptoms progress with continued exposure to numbness of the part (which appears white, yellow-white, or mottled bluish-white). The part becomes cold, hard, and insensitive to touch or deep pressure. In mild cases, local signs subside within a few days.

In some cases, the erythema may persist for several weeks or return abruptly under the slightest exposure to cold. This hypersensitivity (chilblain, pernio) developing in a person previously frostbitten exhibits local areas of congestion that may become inflamed and even ulcerate. This ulcer is often initiated by exercise or exposure to heat causing itching and stinging sensations in the ulcerated area.

Management.   The prevention of frostbite is more important than its cure: feet must be kept dry, moist socks must be changed frequently, and shoes must not be so tight as to restrict adequate toe and heel movement. If the skin is livid and obviously not gangrenous, first aid consists of brief rewarming of the affected part(s) with body heat, warm air, or tepid water. Strong heat should never be applied immediately nor should the area be rubbed. Before wrapping the part(s) in cotton/wool, gauze should be placed between affected digits. Once the tissue destruction process has been halted, the part(s) should be kept mildly cool to reduce secondary edema and ease the metabolic demands called for by the injured tissues.

In cases of deep frostbite, the skin appears hard and will not move over bony ridges. Never attempt to thaw the frostbitten area if there is a chance of refreezing. It is better to leave the part frozen until transportation to specialized care can be made because refreezing a thawed extremity causes severe and disabling damage. Much of what appears to be devitalized tissue may return to normal with proper care; ie, frostbite often appears worse on first examination than it really is.

Burns and Scalds

Burns are common sources of trauma in industry and home accidents. They constitute any injury caused by contact with heat, flame, chemicals, electricity, or radiation. First- and second-degree burns are referred to as partial-thickness burns; third-degree burns, as full-thickness burns. For the most part, burns caused by agents other than heat are treated as heat burns. Sunburn is the most common type of burn seen in sports, but other types of burns are occasionally seen in land and water vehicle-driven sports.

Management.   First aid in burns requires immediate removal from the source of heat, followed immediately by cool douching or applications (eg, strong ice tea wraps) for 30 minutes to 1-1/2 hours, depending on severity, to reduce blisters and pain. Steps should also be taken to protect from infection and to manage any accompanying shock. Topical vitamin E, honey, or aloe are often helpful once the pain reduces.

Note:   Fluori-methane or ethyl chloride may be used to alleviate the pain of first-degree and limited second-degree burns. The Spra-Pak nozzle should be used that offers a mist-like spray to lessen the impact of the vapocoolant on the affected area. Spray lightly until the skin just hints of frost, but never frost the skin.

Sunburn

Acute Form.   The acute form is usually from sunburn producing varying degrees of pain, tenderness, erythema, blisters, and crusts. Sunburn is usually of greatest concern early in the season before the skin has had a chance to accommodate by thickening and tanning. Prevention for sunburn is provided by hats, clothing, and sunscreens; however, sunscreens are quickly washed away by the sweating athlete or worker.

Chronic Form.   Chronic actinic injury produces premature skin wrinkling, lentigines, and, more seriously, predisposes actinic keratoses, basal-cell carcinomas, and squamous-cell carcinomas. Basal-cell carcinomas do not metastasize, but they can deeply invade adjacent tissues. The result may be severe disfigurement, especially about the face and ears. An early sign is a small sore or mass that heals slowly and bleeds readily. Squamous-cell carcinomas are commonly sited on the face, lips, or back of the hands. They tend to grow slower than basal-cell carcinomas, do not bleed as readily, aggressively metastasize, disfigure, and lead to disability and death. Early referral to a dermatologist should be obvious.

Bites and Stings

Animal and severe insect bites are not common in sports, but they occasionally occur to a degree greater than an annoyance. Strangers to a residential area (utility servicemen, meter readers, door-to-door salesmen, postmen, etc) are especially vulnerable to dog bites.

Any physician should be prepared to render at least first aid before transport to specialized facilities if necessary. Common occurrences include dog bites, snake bites, marine bites, and insect bites (eg, bee, hornet, wasp, spider). Some normally minor insect bites may cause death-threatening anaphylaxis in sensitive people.


Acute Traumatic Gangrene

This is a form of direct gangrene where the blood supply has been restricted by traumatic obliteration. A hand or foot is usually affected. The disease usually arises from extensive laceration or a crushing contusion in which extensive soft tissues and often the bones of the part are involved. When dirt or debris are ground into the wound, tetanus and gas gangrene are always potential complications.

Emergency Care.   First aid consists of cold and compression and what other means are available to control pain and hemorrhage. If available, dusting with a sulfa powder or equivalent is often recommended but avoid strong antiseptics that tend to further devitalize tissues. Immediate referral is necessary for tetanus antitoxin, antibiotics, and possible amputation.

Trauma of the Nails and Fingertips

As with finger nailbed injuries, toe nailbed injuries are common in sports where shoes require little or no toe protection. The degree of injury varies from slight nail splits to complete avulsion at the base. As the nailbed is contiguous with the periosteum of the underlying bone, bleeding may be associated with phalanx fracture or a crush injury. Crushing injuries, however, are much more common than nailbed avulsions.

General Management.   In uncomplicated nail avulsions, apply cold immediately to reduce bleeding and swelling. An avulsed nail should be repositioned and a light pressure bandage applied to keep it from snagging socks, gloves, or other objects until it painlessly separates by itself. Care must be taken not to bandage the distal end so tightly that drainage is restricted. A longer shoe or glove may be temporarily necessary to allow for protection without increasing pressure. If a painful subungual hematoma develops from lack of drainage, referral is necessary for surgical relief.

Subungual Hematoma.   If a painful blood pool develops from lack of drainage, referral may be necessary for relief. Some sports physicians and trainers use a paper clip heated in flame to incandescence, allowed to cool somewhat, and then thrust through the intervening nail whereupon it strikes the entrapped blood pool that immediately cools the clip. Hirata states that this method is crude but effective, causes little if any discomfort, and affords immediate relief. The channel created offers a track for drainage, but it also affords a door for secondary infection that may later require excision of the overlying nail. Secondary osteomyelitis is always a threat.

Paronychia.   Acute, sometimes chronic, bacterial infection of folds of skin near a fingernail or toenail is not uncommon, especially if an ingrown nail, wound, or chronic irritation (eg, detergents) is present. Biting the fingernails encourages the infection, as does repeated trauma as seen with baseball catchers. A common first-aid treatment consists of soaking the digit in a hot 1% Lysol solution for several minutes and then painting 3% thymol in chloroform beneath the nail fold. Surgery may be required in severe cases. A method of prevention is cutting the toenail's tip square rather than rounded and bathing the feet at least once daily and drying them thoroughly.

Tetanus

Tetanus is an acute, often fatal (50% in the unimmune) illness characterized by tonic muscular spasm and hyperreflexia, resulting in lockjaw, general muscle spasm, opisthotonus, glottal spasm, convulsions and seizure attacks. It is caused by a neurotoxin whose spores enter the body through a wound. An athlete involved in contact sports is thus frequently exposed due to the high incidence of injury. The incubation period is 1--3 weeks.


Erysipelas

This debilitating condition, more common in basketball elbow blows than in other sports trauma, can attack an athlete with low resistance who has received a head injury. A bright red, hot lesion (St. Anthony's fire) appears in the infected skin, peaking 4--8 days after injury and infection. Upon suspicion of erysipelas, immediate referral to a medical physician should be made. The typical immediate treatment is a wide-band antibiotic.

While the infection is active, the patient's vision and timing are impaired for 2--3 months to some degree, some balding may occur, and associated apathy and listlessness are common. It usually takes an athlete about 6 weeks to recover his full competition strength, but symptoms begin to ebb after 3 weeks. A high-protein, high-vitamin/mineral diet is usually recommended during recuperation.


Stomatitis

Stomatitis is a comprehensive inflammation of the oral mucosa. In general practice, canker-sore lesions of the mouth are commonly associated with systemic disease, vitamin C or riboflavin deficiency, drug allergy, denture irritation, or of a visceral-reflex nature (usually gastric or pulmonary). In athletics, stomatitis can usually be traced to a poor-fitting mouthpiece (eg, football, boxing), which cause the gums to become red, swollen, sore, and the tongue to become large and thick. Salivation is usually marked. A football helmet's chinstrap can exert considerable pressure on an ill-fitted mouthpiece. First aid requires a bland mouthwash. Underlying systemic conditions should be treated appropriately, and dental referral should be made to determine proper mouthpiece adjustment.


Sensitivity Eczema (Atopic or Allergic Dermatitis)

Eczema is a general term referring to any type of atopic, atoxic, allergic, or idiopathic rash. This "catch all" term, eczema, is a ubiquitous category under which are classed various forms of dermatitis, and the allotment varies with different authorities.

Clinical Features.   Eczema generally applies to a superficial acute, subacute, or chronic inflammatory process of the skin characterized by early redness, burning, itching, minute vesicles and papules possibly leading to weeping, oozing, pustules, crusting, late scaling, lichenification, and sometimes pigmentation. In some people, lesions appear immediately after exposure; in others, several days may pass; in still others, many exposures may be necessary to lower resistance enough to obtain a reaction. Rarely is a person sensitive to just one irritant. Susceptibility to one irritant appears to establish a sensitivity reaction to two or more irritants.

Etiology.   The cause may be exogenous (eg, adhesive tape, wool, soaps, cosmetics, gasoline) or endogenous (eg, food allergy, drugs, neurosis). Common causes are external irritants, especially with a person who has inherited or acquired sensitive skin, yet the skin of most people is potentially sensitive to an irritant after long and repeated exposure. Some researchers believe, because the inflammation appears most often on exposed skin surfaces (ie, face, neck, arms, hands), that some type of microtrauma is the exciting cause (eg, soaps, sunlight, pollens, wind, dust, dust mites, or environmental chemicals). Another common cause is a systemic reaction to a prescribed drug or use of an over-the-counter medical preparation.

Sometimes the area of sensitivity is far removed from the site of contact. In athletics, ankle tape or a knee painted with benzoin as a base for tape has been shown to be the cause of swollen irritated eyelids.

Sensitivity Test.   A patch test can determine an individual's degree of sensitivity to many irritants. First, have the patient prepare a careful record of everything touched and used as part of normal activities. Second, hold the material (eg, wool patch) on a tender area of skin, cover it with Saran Wrap, and secure it with adhesive tape. Remove the patch after 2 days and examine for a sensitivity reaction. The tender skin just above or below the inner elbow is usually used. If the irritant is suspected to be a powder, chalk, dust, or a noncaustic liquid (eg, benzoin), saturate a gauze square with the substance, and secure it as described. Troublesome cases required referral to an allergist.

Stasic Eczema

Venous insufficiency usually arises in ankles or lower legs as a result of tight ankle wraps or binding from high shoes. Keeping in mind that muscle action is necessary to drain the lower extremities, venous pooling is often seen in typists and others who spend many hours sitting. Thus, the cause may be either blockage or inactivity. The result is congestion, brownish pigmentation in chronic cases, and later scaling and weeping. Repeated episodes lead to frank edema and phlebitis, possible thrombosis. Chronic scratching leads to secondary infection; and if left unmanaged, dangerous cellulitis, with or without ulceration, develops. Varicose veins, ulceration, thrombophlebitis, and secondary infection are always a threat.

First aid may consist of elevating the involved limb and using a paste (eg, 5% ichthtol in Lassar's paste) on open lesions. Therapy must address the cause (which may be no more than walking) and offer counsel in preventing aggravating factors.


Decubitus Ulcers

One usually thinks of pressure ulcers as being restricted to the those confined to bed for long durations with little movement such as in the poststroke syndrome. But this is not true. Pressure sores on the feet, for example, are sometimes experienced by the athlete early in the season, especially when resistance is low. They are caused by compression and mild trauma. Anybody who grins and bears blistering from tight shoes may become afflicted.

Clinical Features.   The clinical picture emphasizes ischemic necrosis and ulceration in an area overlying a bony prominence where prolonged external pressure has been applied. It begins as soft red skin whose redness disappears on pressure. It then progresses to a deeper redness, induration, edema, and sometimes blistering and desquamation is seen. In the later stages, the skin is necrotic and the lesion extends through fat, muscle, and bone with typical complications.

Management.   To aid granulation and healing, an early first-aid measure used is to coat the lesion with a fresh 5% aqueous solution of tannic acid, then cover the coat with padded tape. Other recommendations are to coat with gentian violet, bismuth violet, or ointment irradiated with radon B, and then cover with a padded adhesive strip. Recurrence can be guarded against by protecting against pressure; ie, padding the shoe's counter with foam rubber about 1/4-inch thick.

Verrucae

Verrucae (warts) are generally considered a contagious viral infection, but clear evidence has not been established. Athletes and physical laborers often present with numerous warts on their hands, wrists, and arms at trauma sites that become irritated by further injury. They may spread.

Management.   A first-aid measure for common warts is the daily application of Freezone, or an equivalent, for 6 days, after which the part is soaked in 118° F water for 30 minutes. If troublesome warts are stubborn, dermatologic referral is advised for cryotherapy, cauterization, electrodesiccation, fulguration, etc.

Plantar Warts

Plantar warts are deeply internal common warts usually surrounded by a callus formation on the sole of the forefoot. They become flattened by body weight, are frequently intensely tender, and greatly impair walking, running, or jumping.

Clinical Features.   Horny layers appear on the sole of the foot that contain a core. This establishes an area of friction between bone and the inside layer of adjacent skin. Differentiation is made from corns and calluses by carefully paring away the surface and noting the tendency to pinpoint bleeding. Plaques of many small closely set plantar warts are called mosaic warts.

Management.   Plantar warts usually occur near the metatarsal heads, thus a metatarsal pad or crescent on the shoe's sole helps to reduce pain during activity. Frequent use of a whirlpool bath at 108° F occasionally helps the plantar wart to soften, extrude, and disappear. Ultrasound, a better alternative, has been found to be highly beneficial in dislodging plantar warts, but it takes many applications a week for several weeks. Other common methods use liquid oxygen or nitrogen.

Keloid

A keloid is a benign tumor featuring a smooth, pink, shiny, often dome-shaped, overgrowth of fibroblastic tissue arising from injured tissue, resembling a scar that did not know when to stop. Keloids are more common in Blacks but can occur in any race. Occasionally, a keloid may develop without a history of injury. Suspicion requires consultation with a dermatologist.


Effects of Certain Skin Residues

Taping is common in athletics, and the residue left from some adhesive tape is rarely completely removed by the after-game shower. Usually more is needed besides soap and water. Commercial solutions are effective, but many contain carbon tetrachloride that requires extreme caution against breathing the fumes. Gasoline, lighter fluid, or other explosive mixtures should never be used. Two football players at Purdue were killed several years ago in a shower-room blast while using gasoline to remove tape residue.

Other residues are often a problem. Dried calamine lotion, flakes, and powders may be removed with a light oil. Nonexplosive cleaning fluids or mild detergents can be used in removing greases, ointments, and rubefacients. Cheesecloth saturated with a light oil (eg, mineral, cottonseed, olive) is helpful in removing skin scales and crusts. A solution of sodium thiosulfate tends to dissolve iodine stains, while spirits of ammonia and alcohol help somewhat in removing gentian violet stains.


      PERSPIRATION RELATED DISORDERS

The Role of General Hygiene

It was explained earlier that many posttraumatic skin disorders and their complications are directly or indirectly associated with poor hygiene that may occur before or during management or be aggravated by poor management and prevention techniques.

It has long been recognized that a thorough showering is a necessity after physical activity to remove accumulated sweat residue, bacteria, dirt, and debris. Because of the postactivity shower routine in athletics, players practice far better habits of cleanliness (are more thoroughly and frequently washed) than those of the general population. The conditioned skin of most athletes adapts well to common bath soaps (Ivory). On rare occasions, a person may be found who is susceptible to alkali irritation and will require a mild nonallergenic-type of pH controlled soap. For dry sensitive skin, Oilatum soap is beneficial.

Usually, a 4--5 minute shower in water at 80° --90° F is sufficient. There is no scientific basis in the habit of following a warm shower with a blast of cold water to "close the pores," but there is in drying off quickly to prevent chill. A study by Harvard Medical School showed that those who showered and then were exposed to activity in chilly air were no more susceptible to the common cold than those who did not shower beforehand.


Hyperhidrosis

Sweat gland overactivity often occurs in the palms, axillae, groin, folds of the elbows or knees, and inframammary region, or it may have a general distribution. The cause of localized excessive sweating is unknown. Hyperhidrosis of the palms and soles is often considered psychogenic. Generalized hyperhidrosis may have an endocrine, febrile, or a central nervous system basis. A rash may be associated that can easily be confused with ringworm.


Bromhidrosis

Excessive feet sweating may be associated with scales, fissures, maceration, and a strong odor. The fetid odor (bromhidrosis) is the result of sweat and cellular debris being decomposed by yeast and bacteria. The patient's perspiration may contain a high amount of urea.

Management.   Bromhidrosis can sometimes be managed with an antiperspirant powder. Scrupulous cleanliness must be maintained. Socks should be undyed, laundered with a bleach, and changed frequently. Alternate three sets of shoes that are dusted frequently with a fungitoxic powder. Some doctors recommend that when the feet are involved, footbaths (saline, alcohol) followed by a soothing astringent (eg, 25% aluminum chloride each night for 3 weeks) usually bring relief. The author has found that daily warm footbaths containing a half cup of bleach are helpful where other methods have failed.

If there is an axillary problem, the hair should be shaved and a nonirritating antiperspirant (eg, zinc oxide lotion) applied after bathing. Only in rare instances is diet a causative factor. Keep in mind that most commercial antiperspirants just force sweat into axillary tissues. At least one study relates this to predispose abscess and even breast cancer.

Miliaria

"Prickly heat" or "heat rash" manifests as a series of pink, pruritic, papolovesicular lesions under tight underwear or protective gear (eg, shoulder pads, rib pads) worn during warm-weather activity. It is not uncommon to football linemen. No corset, girdle, or protective uniform can be considered "cool" for the overweight. The disorder is brought on by (1) excessive sweating with a distinct decrease of water content or (2) a partial obstruction (congenital) to the ducts of the sweat glands forcing sweat to escape into the epidermis. This latter state is better labeled atopic eczema.

Management.   A first-aid measure is to freely dust the body with talcum before exercise and follow exercise with a tepid shower and then an alcohol rub. Preventive measures include keeping the skin cool and dry and avoiding activity inducing excessive perspiration, which are almost impossible in athletics.

Hidradenitis

Hidradenitis is an inflammation of sweat glands, often resembling furuncles, characterized by an intensely painful inflammatory process resulting in obstruction and rupture of the sweat ducts. Discharge and sinus tract formation are common. Signs of severe chronic recurrent suppurative hidradenitis are pea-like lumps of the axillae or groin sweat glands. They infrequently arise around the nipples or anus. Immediate referral to a dermatologist is recommended in severe cases. In fact, any growth in the axillae or groin demands a cross-profession second opinion.


Pruritus Ani

This is a common complaint among females and athletes of either gender. Excessive sweating and poor hygiene are factors unless the condition has a psychic origin. Pruritus ani is characterized by an intensely itchy but mild eczematous-type lesion involving the perianal skin. The cause is unknown, but secondary infection from scratching, sensitivity to certain underwear fabrics (eg, nylon), environmental chemicals (eg, laundry soaps and softeners) may be involved.