Herpes gladiatorum is one of the most infectious of herpes-caused diseases, and is transmissible by skin-to-skin contact. The disease was first described in the 1960s in the ''

New England Journal of Medicine ''The New England Journal of Medicine'' (''NEJM'') is a weekly medical journal published by the Massachusetts Medical Society. Founded in 1812, the journal is among the most prestigious peer-reviewed medical journals. Its 2023 impact factor was ...

''. It is caused by contagious infection with human

herpes simplex virus Herpes simplex virus 1 and 2 (HSV-1 and HSV-2) are two members of the Herpesviridae#Human herpesvirus types, human ''Herpesviridae'' family, a set of viruses that produce Viral disease, viral infections in the majority of humans. Both HSV-1 a ...

type 1 (HSV-1), which more commonly causes oral herpes (cold sores). Another strain, HSV-2 usually causes

genital herpes Genital herpes is a herpes infection of the genitals caused by the herpes simplex virus (HSV). Most people either have no or mild symptoms and thus do not know they are infected. When symptoms do occur, they typically include small blisters ...

, although the strains are very similar and either can cause herpes in any location. While the disease is commonly passed through normal human contact, it is strongly associated with

contact sport A contact sport is any sport where physical contact between competitors, or their environment, is an integral part of the game. For example, gridiron football. Contact may come about as the result of intentional or incidental actions by the playe ...

s—

outbreak In epidemiology, an outbreak is a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season. It may affect a small and localized group or impact upon thousands of people across an entire ...

s in sporting clubs being relatively common. Other names for the disease are herpes rugbiorum or "scrumpox" (after

rugby football Rugby football is the collective name for the team sports of rugby union or rugby league. Rugby football started at Rugby School in Rugby, Warwickshire, England, where the rules were first codified in 1845. Forms of football in which the ball ...

), "wrestler's herpes" or "mat pox" (after

wrestling Wrestling is a martial art, combat sport, and form of entertainment that involves grappling with an opponent and striving to obtain a position of advantage through different throws or techniques, within a given ruleset. Wrestling involves di ...

). In one of the largest outbreaks ever among high-school wrestlers at a four-week intensive training camp, HSV was identified in 60 of 175 wrestlers. Lesions were on the head in 73 percent of the wrestlers, the extremities in 42 percent, and the trunk in 28 percent. Physical symptoms sometimes recur in the skin. Previous adolescent HSV-1 seroconversion would preclude most herpes gladiatorum, but being that stress and trauma are recognized triggers, such a person would be likely to infect others.

Signs and symptoms

Herpes gladiatorum is characterized by a rash with clusters of sometimes painful fluid-filled

blister A blister is a small pocket of body fluid (lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled ...

s, often on the neck, chest, face, stomach, and legs. The infection is often accompanied by

lymphadenopathy Lymphadenopathy or adenopathy is a disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes. In c ...

(enlargement of the

lymph node A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that includ ...

s),

fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...

sore throat Sore throat, also known as throat pain, is pain or irritation of the throat. The majority of sore throats are caused by a virus, for which antibiotics are not helpful. For sore throat caused by bacteria (GAS), treatment with antibiotics may hel ...

, and

headache A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of Depression (mood), depression in those with severe ...

. Often, the accompanying symptoms are much more of an inconvenience than the actual skin blisters and rash. Each blister contains infectious virus particles (

virion A virion (plural, ''viria'' or ''virions'') is an inert virus particle capable of invading a Cell (biology), cell. Upon entering the cell, the virion disassembles and the genetic material from the virus takes control of the cell infrastructure, t ...

s). Close contact, particularly abrasive contact as found in contact sports, causes the infected blisters to burst and pass the infection along. Autoinoculation (self-infection) can occur through self-contact, leading to infection at multiple sites on the body. Herpes gladiatorum symptoms may last up to a few weeks, and if they occur during the first outbreak, they can be more pronounced. In recurrences of the ailment, symptoms are milder, even if lesions still tend to occur. With recurrent infections scabs may form at 3 days yet the lesions are still considered infectious up until 6.4 days after starting oral antiviral medications. Healing takes place without leaving

scar A scar (or scar tissue) is an area of fibrosis, fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other Organ (anatomy), organs, and biological tissue, t ...

s. It is possible that the condition evolves

asymptomatic Asymptomatic (or clinically silent) is an adjective categorising the medical conditions (i.e., injuries or diseases) that patients carry but without experiencing their symptoms, despite an explicit diagnosis (e.g., a positive medical test). P ...

ally and sores are never present.

Causes

Herpes gladiatorum is a skin infection primarily caused by the

. The virus infects the cells in the epidermal layer of the skin. The initial

viral replication Viral replication is the formation of biological viruses during the infection process in the target host cells. Viruses must first get into the cell before viral replication can occur. Through the generation of abundant copies of its genome ...

occurs at the entry site in the skin or

mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It ...

. The infections caused by a HSV Type 1 virus may be primary or recurrent. Studies show that even though most of the individuals who are exposed to the

virus A virus is a submicroscopic infectious agent that replicates only inside the living Cell (biology), cells of an organism. Viruses infect all life forms, from animals and plants to microorganisms, including bacteria and archaea. Viruses are ...

get infected, only 10% from them will develop sores as well. These types of sores appear within two to twenty days after exposure and usually do not last longer than ten days. Primary infections usually heal completely without leaving scars but the virus that caused the infection in the first place remains in the body in a latent state. This is the reason why most of the people experience recurrences even after the condition is taken care of. The virus moves to the

nerve cells A neuron (American English), neurone (British English), or nerve cell, is an excitable cell that fires electric signals called action potentials across a neural network in the nervous system. They are located in the nervous system and help to ...

from where it can reactivate. Once the condition has recurred, it is normally a mild infection. The infection may be triggered by several external factors such as sun exposure or trauma. Infection with either type of the HSV viruses occurs in the following way: First, the virus comes in contact with damaged skin, and then it goes to the nuclei of the cells and reproduces or replicates. The blisters and

ulcers An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing ...

formed on the skin are a result of the destruction of infected cells. In its latent form, the virus does not reproduce or replicate until recurrence is triggered by different factors.

Pathophysiology

Herpes gladiatorum is transmitted by direct contact with skin lesions caused by a herpes simplex virus. This is the main reason why the condition is often found in wrestlers. It is believed that the virus may be transmitted through infected wrestlers' mats, but this is still subject of research since the virus cannot live long enough outside the body in order to be able to cause an infection. Direct contact with an infected person or infected

secretion Secretion is the movement of material from one point to another, such as a secreted chemical substance from a cell or gland. In contrast, excretion is the removal of certain substances or waste products from a cell or organism. The classical mec ...

s is undoubtedly the main way in which this virus may be transmitted. It is also believed that wearing abrasive clothing may increase the chances to get infected with this type of virus. Shirts made of

polyester Polyester is a category of polymers that contain one or two ester linkages in every repeat unit of their main chain. As a specific material, it most commonly refers to a type called polyethylene terephthalate (PET). Polyesters include some natura ...

and cotton may cause frictions that lead to small breaks in the skin which makes it easier to contract the infection. Studies in which athletes were wearing 100% cotton shirts showed a decrease in the number of herpes gladiatorum cases. The spread is facilitated when a sore is present but it can happen in its absence as well. The patients may know that the virus is present on the skin when they experience the so-called "

prodromal In medicine, a prodrome is an early Medical sign, sign or symptom (or set of signs and symptoms, referred to as prodromal symptoms) that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. More spe ...

symptoms". These include

itch An itch (also known as pruritus) is a sensation that causes a strong desire or reflex to scratch. Itches have resisted many attempts to be classified as any one type of sensory experience. Itches have many similarities to pain, and while both ...

ing or tingling on the skin, right before the blisters or lesions appear. The virus may spread since the first symptoms appear until lesions are completely healed. The

incubation period Incubation period (also known as the latent period or latency period) is the time elapsed between exposure to a pathogenic organism, a chemical, or ionizing radiation, radiation, and when symptoms and signs are first apparent. In a typical infect ...

is situated between 3 and 14 days. This means that a person will experience the symptoms within 14 days after he or she contracted the infection. This type of virus may be transmitted even if the symptoms are not yet present. Some individuals can have very mild symptoms that may not be taken as herpes symptoms and the patient may not recognize them. The asymptomatic transmission occurs when the infection is spread between outbreaks.

Similar infections

Herpes gladiatorum is only caused by the

Shingles Shingles, also known as herpes zoster or zona, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. T ...

, also manifesting as skin rashes with blisters, is caused by a different virus, herpes zoster. Other agents may cause skin infections, for example

ringworm Dermatophytosis, also known as tinea and ringworm, is a mycosis, fungal infection of the skin (a dermatomycosis), that may affect skin, hair, and nails. Typically it results in a red, itchy, scaly, circular rash. Hair loss may occur in the a ...

is primarily due to the fungal dermatophyte, ''T. tonsurans''.

Impetigo Impetigo is a contagious bacterial infection that involves the superficial skin. The most common presentation is yellowish crusts on the face, arms, or legs. Less commonly there may be large blisters which affect the groin or armpits. The les ...

cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...

folliculitis Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head. A ...

and carbuncles are usually due to ''Staphylococcus aureus'' or Beta-hemolytic streptococcus bacteria. These less common forms can be potentially more serious. Anti-viral treatments will not have an effect in non-viral cases. Bacterial infections must be treated with

antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...

s and fungal infections with anti-fungal medication.

Prevention

Key measures to prevent outbreaks of the disease are maintaining

hygiene Hygiene is a set of practices performed to preserve health. According to the World Health Organization (WHO), "Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Personal hygiene refer ...

standards and using screening to exclude persons with suspicious infections from engaging in contact sports. A skin check performed before practice or competition takes place can identify individuals who should be evaluated, and if necessary treated by a healthcare professional. In certain situations, i.e. participating in wrestling camps, consider placing participants on valacyclovir 1GM daily for the duration of camp. 10-year study has shown 89.5% reduction in outbreaks and probable prevention of contracting the virus. Medication must be started 5 days before participation to ensure proper concentrations exist.Anderson BJ, McGuire D, Reed, M, Foster M, Ortiz D. Prophylactic Valacyclovir to Prevent Outbreaks of Primary Herpes Gladiatorum at a 28-day camp: a 10-year review.''Clin J Sports Med''. 2016. 26:4: 272–8.

Treatment

Herpes outbreaks should be treated with antiviral medications like Acyclovir, Valacyclovir, or Famcyclovir, each of which is available in tablet form. Oral antiviral medication is often used as a prophylactic to suppress or prevent outbreaks from occurring. The recommended dosage for suppression therapy for recurrent outbreaks is 1,000 mg of valacyclovir once a day or 400 mg Acyclovir taken twice a day. In addition to preventing outbreaks, these medications greatly reduce the chance of infecting someone while the patient is not having an outbreak. Often, people have regular outbreaks of anywhere from 1 to 10 times per year, but stress (because the virus lies next to the nerve cells), or a weakened immune system due to a temporary or permanent illness can also spark outbreaks. Some people become infected but fail to ever have a single outbreak, although they remain carriers of the virus and can pass the disease on to an uninfected person through asymptomatic shedding (when the virus is active on the skin but rashes or blisters do not appear). The use of antiviral medications has been shown to be effective in preventing acquisition of the herpes virus. Specific usage of these agents focus on wrestling camps where intense contact between individuals occur on a daily basis over several weeks. They have also been used for large outbreaks during seasonal competition, but further research needs to be performed to verify efficacy.

References

{{Viral cutaneous conditions Virus-related cutaneous conditions Sports medicine Herpes simplex virus–associated diseases