Necessary Protocol to Reduce Skin Infections in Wrestling

Skin infections in sports are a common issue that can affect any athlete, regardless of the sport in which they participate. While any athlete can contract a skin infection, the primary cause of spread is skin-to-skin contact, which happens most in sports such as wrestling.

In 2016, Ashack¹ published a study of infection rates in high school sports which found that the rate of infection for wrestlers was 28.56/100,000 exposures; the next highest was football at 2.32/100,00 exposures. With infection rates in wrestling being 10 times more prevalent, this creates concern due to ease of transmission and potential long-term consequences.

In recent years, a collegiate wrestler contracted a bacterial infection leading to necrotizing fasciitis of his leg, requiring significant debridement and skin grafting. In an attempt to avoid these consequences, the NFHS, NCAA, UWW and USA Wrestling have established protocols to reduce the risk of transmission of skin infections. Each of these organizations has determined that the following steps are necessary to mitigate the spread of infectious agents.

• Recognition of infectious agents: bacterial, viral, fungal

• Performing skin checks

• Follow skin sheet guidelines in treatment

Recognition of these agents is key. If an individual is unable to recognize skin infections during a skin check, it will be impossible to prevent the spread of infection. It is imperative that the individual performing skin checks understands the risk factors that lead to the formation of a skin infection, how each of the most common infectious agents present, and key factors in preventing their transmission to other athletes.

Bacterial infections usually develop on injured skin. These infections are primarily due to Staph aureus, a gram-positive organism that can lead to cellulitis, folliculitis, impetigo and abscess formation. Cellulitis presents as a warm, red site with firm texture.

Folliculitis generally has a collection of pus at the base of a hair follicle and there can be numerous follicles grouped together. These lesions are typically 2 millimeters in size and can be associated with cellulitis.

Impetigo usually presents with weeping, crustiness and can progress to bullae or sacs of purulent material. Upon opening, the bullae will leave a crater in the skin.

Abscesses and boils are a collection of pus and may reach several centimeters in diameter. When managing an abscess, be cautious due to potential methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA is a variant of Staphylococcus aureus that is extremely contagious and can lead to joint infections and sepsis.

The most common viral skin infections in wrestling are herpes gladiatorum and molluscum contagiosum. Herpes gladiatorum is due to herpes simplex type I (HSV-1). It is spread by direct contact with an infected individual. In more than 90% of cases, lesions develop within eight days following exposure2. Greater than 70% of these outbreaks will occur on the head, face or neck with 49% of the lesions presenting on the right side of the face due to 85% of these athletes being right-handed3.

Primary HSV-1 outbreaks on the face usually develop with fever (>101.5F), sore throat, significant adenopathy, redness to face and notable vesicle formation4. Recurring HSV-1 outbreaks will typically present at or very near the same site as the primary infection due to the infection lying dormant in the local dermatome. When not properly treated, vesicles can last up to 10-14 days. During this entire time, the athlete is contagious.

What is especially problematic about this virus is that it is contagious up to three days before vesicle formation. Many times, the only way to tell if an outbreak is going to happen prior to vesicle formation is itching, burning or tingling occurring around teventual outbreak. This issue is the primary reason why HSV-1 can spread so easily within a team.

Molluscum contagiosum is due to a poxvirus and is spread by contact. These lesions present as a small papule, 2-3 millimeters in diameter, diffusely distributed on the body. Transmission can occur via papule breaking open and its contents having contact with another athlete. There are no associated systemic symptoms developed with this infection.

A common and contagious fungal infection in wrestling is tinea (ringworm). It is commonly spread by direct contact with infected individuals. Lesions will appear as a small red spot and spread in a circular fashion. The perimeter of each lesion can be slightly raised with flakiness, but the center usually has clearance. Fungal infections have a predilection for the head and face, especially the scalp due to higher lipid (fat) content in the skin.

Recent introduction of women’s wrestling has led to increased observance of ringworm developing around the back of the ears, base of neck and along the strap lines from the head gear, especially along the scalp. Scalp lesions can be associated with hair loss and secondary infections.

Performing skin checks appropriately is the next step in mitigating the spread of skin infections. Skin checks should be performed by certified athletic trainers, referees, coaches or individuals who are well acquainted with recognizing these conditions. It is recommended that skin checks are performed on a routine basis, not just at competitions. With teams competing more often in tournaments than duals, most of the competitions occur on the weekends. With propagation taking three-plus days for their development, ideally skin checks should be done on Tuesdays and closely monitored throughout the remainder of the week. The larger the tournament the greater the risk for these infections to develop.

If, during skin checks, a suspicious lesion is found, removal from practice/competition is imperative to prevent transmission. For competitions, consideration should be given to having a physician present who is trained in skin infection etiology. Due to differing opinions and a lack of knowledge about this topic in the general medical community, if there is no physician at a competition, the final determination about a skin lesion still needs to be made, which is when having a completed skin sheet can help the medical staff make decisions regarding participation.

Skin sheets allow for a physician who is not going to attend a competition to diagnose lesions and communicate return-to-play timelines. Skin sheets include guidelines for minimum medicinal treatment prior to return to wrestling for each type of skin infection, these guidelines may differ between entities.

Treating skin conditions in wrestling is predicated on two things: treating the individual and preventing transmission to other athletes. If a skin infection develops on a non-contact sport athlete, the risk of transmission is miniscule. In wrestling, however, the individual must be treated to prevent transmission. Minimum treatment guidelines are in place for just that reason. It is best practice to refer an athlete to a physician who is well acquainted with the guidelines should a suspicious lesion be found.

Recommendations regarding accurate recognition of infectious agents, conducting proper skin checks and compliance with skin sheet guidelines to properly treat skin infections, were initiated by the NFHS more than 30 years ago. Its effectiveness, when properly followed, has proven to be a deterrent in skin infection propagation. It has been so effective that it has since been adopted by the NCAA, USA Wrestling and UWW. Following these recommendations will help protect athletes, reducing their risk of contracting skin infections and transmission to others.

Other references can be accessed through the following NFHS links: NFHS Wrestling Skin Lesion Form: https://assets.nfhs.org/storyblok/f/1022696/x/6a13d9f6c0/2026-27-nfhs-wrestling-skinlesion-form-final-5-5-26.pdf

NFHS General Guidelines for Sports Hygiene, Skin Infections and Communicable Diseases: https://a-us.storyblok.com/f/1022696/x/2beee72c95/2025-nfhs-general-guidelines-for-sports-hygiene-skin-infections-and-communicable-diseases-final-4-27-25.pdf

NFHS Sports Related Skin Infections Position Statement and Guidelines: https://a-us.storyblok.com/f/1022696/x/aa4268a0ee/2025-nfhs-sports-related-skin-infections-position-statement-and-guidelines-final-4-27-25.pdf

Communicable Skin Infections (NFHS Learning Center online course): https://nfhslearn.com/courses/communicable-skin-infections

References:

1 Ashack KA, Burton KA, Johnson TR, Currie DW, Comstock RD, Dellavalle RP. Skin infections among US high school athletes: A national survey. JAAD. 74(4);April 2016:769-684. 2,3,4 Anderson BJ. The Epidemiology and clinical Analysis of Several Outbreaks of Herpes Gladiatorum. MSSE.35(11):1809-1814. 5 The Mat Doc app. Developer: BJ Anderson (2025). MatDoc. Ver: 1.1710.10. App Store: https://apps.apple.com/us/app/matdoc/id487520461

Dr. B. J. Anderson presently works as primary care and sports medicine physician at Boynton Health Service, University of Minnesota. He is a past member of the NFHS Sports Medicine Advisory Committee. Dr. Anderson presently serves as team physician for Augsburg University football and wrestling teams.

Marissa Lindback LAT, ATC presently serves as ATC at Augsburg University since 2017. She is a graduate of Augsburg University and NDSU with Master’s degree in athletic training.