RINGWORM IN WRESTLERS | TINEA GLADIATORUM

INTRODUCTION
Tinea Gladiatorum is an infection that is getting more attention in wrestling as well as scientific
circles.
Due to the virulence and persistence of this condition, it is considered to be a different
condition from Tinea capitis and Tinea corporis even though they are all sharing the same
causitive fungus. Our management of the condition should reflect this understanding.
A further problem is that many carriers of the fungal spores are asymptomatic, in that they
show no symptoms of Tinea Gladiatorum. They can however spread the disease just as easily as
a person having ringworm. Up to 50% of people can have carrier status without showing any
symptoms, according to a South African study.
Although the condition is associated with discomfort (itching), disfigurement (hair loss, lesions
on body) and secondary infections (bacterial and viral), it is not deadly and most of the time
considered nothing more than a nuisance.
GUIDELINES and RESOURCES
Medicine in competitive sport is usually caught between two opposite poles. On the one hand
is the safety and health of the athlete and on the other, the ability to return to play. The aim is
to take all factors into account to have healthy, competing athletes.
South Africa is considered a third-world country. In terms of medicine, guidelines should take
clinical factors as well as available resources into account. The WHO continually publishes
guidelines specifically for resource-poor settings. Unfortunately, when it comes to sports
medicine, we are bound to guidelines from first-world countries with abundant resources such
as team doctors, team dieticians and even a team dermatologist.
PROPOSED CHANGE TO GUIDELINES
As it stands, a ringworm infection can lead to exclusion from competition wrestling. The blame
for this exclusion is usually laid at the feet of the health and safety official present at the
competition. The club and the wrestler is never held accountable for a ringworm outbreak that
was not actively treated or a lesion that was inadequately treated. This should change. The club
should take responsibility for it’s wrestlers.
How will we change this?

I propose the following:

 1) Preventative and management strategy as set out below to be
implemented in local clubs

2) Strict policy (as before) for local and regional

competitions. With the following minor changes:
a. For lesions on the body – Wrestler can compete if a
medical certificate is presented that confirms ongoing
treatment for at least 48-72 hours.
b. For lesions on the scalp – Wrestler can compete if a
medical certificate is presented that confirms ongoing
treatment for at least 14 days.

3) National Competition: A decision to be made on a case-by-

case basis. I suggest exclusion from competition due to the
following (Occlusion can still be applied):
a. 3 or more lesions on scalp of less than 3 cm;
b. 5 or more lesions on body of less than 3 cm;
c. 3-5 cm single lesion.

PREVENTION and MANAGEMENT STRATEGY

1. PREVENTION
Wrestling mats are probably not to blame for the spread of ringworms. The studies are
conflicting and common-sense dictates that the lower body should have been affected more
often than the head and torso. Wrestling mats should, however, be cleaned regularly to
prevent bacterial and bloodborne infections such as impetigo and hepatitis. The following 3 S’s
is, however, effective preventative measures:
“Shower”
Only 10% of wrestlers shower directly after wrestling according to an American study. We
should remind wrestlers about this basic preventative measure.
“Screening”
Designated person to check some of the wrestlers on a weekly basis – 3-5 wrestlers per week.
Maybe get a doctor on WhatsApp to confirm whether something is a ringworm or not.
“Siblings”
Members of the same household (of an affected wrestler) should preferably be checked as well.
Consider using antifungal shampoo for the family for a few days. Bedding should also be
laundered as soon as a diagnosis of ringworm has been made.
2. TREATMENT
As soon as a diagnosis has been made, the correct treatment should be started for the wrestler.
Get a local doctor on board to be ready and willing to prescribe the medication. See Addendum
A – Treatment of Tinea Gladiatorum (letter to local doctor).
3. PROPHYLAXIS
1) Shampoo
Because of the high incidence of asymptomatic carriers of tinea, we suggest that an antifungal
shampoo be used on a regular basis by wrestlers. Especially during outbreaks in the club or a
household.

2) Medication
Fluconazole is a safe and effective drug to prevent Tinea gladiatorum. It can be given in two
ways:
a) “Pulse therapy” - once daily for 3 days at the start of the wrestling season and then a
repeat three-day-course six weeks later.
b) “Weekly therapy” - a once-weekly dose for the entire wrestling season.
See Addendum B – Fluconazole prophylaxis
 ADDENDUM A – Treatment of Tinea Gladiatorum (letter to local doctor)
To whom it may concern
Esteemed colleague,

One of the greatest challenges in competitive wrestling is recurrent skin infections. Of these,
Tinea Gladiatorum is the most common. Unfortunately it is often treated in the same manner
as Tinea Capitis and Tinea Corporis. The consensus is moving towards a more aggressive
approach due to the unique epidemiology and clinical manifestation of Tinea Gladiatorum.

With the wrestler in front of you in mind, please consider the following medication:
1) TOPICAL TREATMENT
a. 1st choice: Terbinafine (eg Lamisil, Terbicil) OR
b. 2nd choice: Miconazole (eg Covarex)
2) AND ORAL TREATMENT
a. 1st choice: Terbinafine
i. <20kg 62.5mg daily
ii. 20-40kg 125mg daily
iii. >40kg 250mg daily
OR
nd
b. 2 choice: Griseofulvin (Microcidal)
i. 10mg/kg per day
ii. Remember: tablets come in 125mg (scored) and 500mg (not scored)

Please consider Ketoconzole Shampoo for the wrestler and the rest of the household, as the
hair acts as a reservoir of the spores and up to 50% of contacts can be asymptomatic carriers of
the fungus.
Do not hesitate to contact me with any further questions

Regards,
Dr W.A.P. von Ludwig
email: [email protected]
 ADDENDUM B – Fluconazole Prophylaxis (letter to local doctor)
To whom it may concern
Esteemed colleague,

One of the greatest challenges in competitive wrestling is recurrent skin infections. Of these,
Tinea Gladiatorum is the most common. Several studies have indicated that prophylaxis works
well in curbing this resilient organism.
With the wrestler in front of you in mind, please consider the following prophylaxis:

Fluconazole 100mg daily for 3 days to be repeated after six weeks

OR
Fluconazole 100mg weekly for the whole season
The 100mg dosage can be changed to 3 mg/kg in younger children.

Please consider intermittent Ketoconazole Shampoo for the wrestler and the rest of the club, as
the hair acts as a reservoir of the spores and up to 50% of contacts can be asymptomatic
carriers of the fungus.
Do not hesitate to contact me with any further questions
Regards,

Dr W.A.P. von Ludwig

email: [email protected]
 ADDENDUM C – Fluconazole (Information for parents)
Ringworm is a common skin infection in wrestlers. Although it is not a serious infection, it can
lead to other, more serious infections such as impetigo, abscesses and boils.

To prevent outbreaks in this wrestling club and outbreaks in other clubs across South Africa, we
have decided to start with a prevention programme that includes medication.
The medication is Fluconazole. It is a medication with an excellent safety profile of more than
40 years. Your child will take it as “pulse therapy” or as a weekly dose.

Please inform your doctor if your child is suffering from one of the following conditions, as this
may be a contraindication to taking fluconazole:

• LIVER OR KIDNEY PROBLEMS

• HEART OR HEART RYTHM PROBLEMS
• PORPHYRIA
Please inform your doctor if your child is on any of the following medications, as this might be a
contraindication to taking fluconazole:

• Erythromycin – an antibiotic used to treat upper respiratory and other infections.

• Quinidine – a medication used to treat heart rhythm abnormalities
• Phenytoin – an epilepsy drug
• Dormicum – an anxiety drug

If your child is on fexofenadine (Telfast, Fexo) we suggest that you half the dose of the
fexofenadine.

The possible side-effects are generally mild and include the following:

• Headache and dizziness

• Nausea and dry mouth
• Sleeplessness
• Heart palpitations

Due to the short duration of the treatment, it is highly unlikely that these side-effects will be a
problem.
Please contact your local doctor if you have any further queries.

Regards,
Dr W.A.P. von Ludwig
email: [email protected]