Herpes Gladiatorum in athletes cover



Herpes gladiatorum (HG) is a cutaneous infection with the herpes simplex virus (HSV) causing a non-genital rash in athletes. It is nearly ubiquitously associated with wrestling where it first gained notiarity at a wrestling camp in 1989.[1]Belongia EA, Goodman JL, Holland EJ, et al. An outbreak of herpes gladiatorum at a high-school wrestling camp. N Engl J Med. 1991;325:906-910. In fact, it is so common among wrestlers that 20% to 40% of college wrestlers will have an outbreak in any given season.[2]Agel J, Ransone J, Dick R, Oppliger R, Marshall SW. Descriptive epidemiology of collegiate men’s wrestling injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 … Continue reading Nearly 90% of cases are subclinical and go unnoticed. In high school athletes, approximately 30% are infected or colonized but only about 3% are aware they carry the virus.[3]Anderson, B. J. “Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling camp.” Japanese Journal of Infectious Diseases 59.1 (2006): 6.
Image 1. Herpes Gladiatorum of the Head, Face and Scalp.[4]Wei, Elizabeth Y., and Daniel T. Coghlin. “Beyond folliculitis: recognizing herpes gladiatorum in adolescent athletes.” The Journal of Pediatrics 190 (2017): 283.

HG is the clinical manifestation of transmission of the HSV virus. Transmission occurs primarily through direct skin-to-skin contact. Sports with increased skin to skin contact include wrestling and rugby. Once an athlete is inoculated, the virus replicates in a sensory ganglion and spreads along the sensory nerve distribution. It often is bilateral and involves multiple dermatomes. The face is involved 70% of the time, with the rest of the body making up the other 30%. Lesions tend to affect the dominant hand, side of head preferred by athlete in the ‘tie position’ in wrestling.

Clinical Presentation

With a primary infection, athletes will have a 4 to 11 day incubation period where infection is subclinical. A prodrome of hyperesthesia and parasthesia can precede cutaneous manifestation and no systemic symptoms are present initially. Once symptomatic, a maculopapular vesicular rash will appear on approximately day 2. They coalesce with a minimally reddened base. In primary infection, athletes will also develop systemic symptoms including malaise, low-grade fever, sore throat, lymphadenopathy, and headache. In addition to the obvious rash, physicians must consider and perform a careful oral exam looking for gingivostomatitis and eye exam looking for herpes keratitis. A fluorescein exam is indicated if the face is affected. Missed herpes keratitis can result in permanent vision loss. The rash can also occur in a beard distribution from autoinnoculation while shaving, a presentation termed Herpetic Sycosis. Secondary HG or recurrence is common but presents with more mild symptoms in the same dermatomal distribution.

Image 2. Primary herpes gladiatorum. Note multiple areas of involvement and regional adenopathy.[5]Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.

Image 2. Recurrent herpes gladiatorum.[6]Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.


Diagnosis can be problematic and is often missed. One study found that on presentation, the correct diagnosis was made only about 10% of the time.[7]Dworkin, Mark S., et al. “Endemic spread of herpes simplex virus type 1 among adolescent wrestlers and their coaches.” The Pediatric infectious disease journal 18.12 (1999): 1108-1109. The differential is broad in athletes and includes are common infections such as cellulitis, impetigo, herpes genitalia, hidradenitis supporativa, pediculosis, scabies, molluscom contagiosum and warts (verrucae).

Laboratory evaluation can help confirm the diagnosis and is recommended in most cases. This is typically performed by direct microbiology with either PCR or viral culture. Viral culture is typically cheaper while PCR is faster. Either one is appropriate depending on lab resources. The Tzank smear is no longer favored due to poor sensitivity and specificity. Serology is not recommended due to high rates of positivity with low rates of active disease.


In most cases, management with valacylovir is fairly straight forward. In primary infection, valacyclovir should be dosed at 1000 mg twice daily (or 20 mg/kg 3 times daily for children <20 kg) for 7-10 days. For recurrent infections, 500 to 1000 mg twice daily for 7 days. Prophylaxis should also be strongly considered in athletes with a history of HG, herpes labialis, or herpes genitalia. Prophylaxis has been shown to decrease risk of HSV acquisition, prevent recurrence of previous, and outbreaks. In one study at a wrestling camp, daily oral valacyclovir decreased recurrent outbreaks by 89.5%, prevented contraction of the virus.[8]Anderson, B. J. "Prophylactic valacyclovir to prevent outbreaks of primary herpes gladiatorum at a 28-day wrestling camp." Japanese Journal of Infectious Diseases 59.1 (2006): 6. Prophylaxis dosing is 500 mg PO daily (if most recent infection >2 years ago) or 1 g PO daily (if most recent infection <2 years ago). This should be initiated about 5 days prior to the season or training camp.
The other major treatment objective is to remove the athlete from participation to prevent transmission to others. This should occur as soon as HG is known or suspected. The National Collegiate Athletic Association (NCAA) and National Federation of High Schools (NFHS) have very clear return to play guidelines (see table 1). Broadly speaking, athletes must have been on antiviral therapy for a certain number of days and their symptoms should be improving.

Table 1. Return to play guidelines for Herpes Gladiatorum (click to enlarge).[9]Peterson, Andrew R., Emma Nash, and B. J. Anderson. “Infectious disease in contact sports.” Sports Health 11.1 (2019): 47-58.


Prevention is the cornerstone of managing HG. Athlete hygiene is key including showering immediately after practice or an event, using your own soap, towels and razors and washing towels immediately after use. Athletes should also wash hands frequently, avoid picking or squeezing lesions, and report any suspicious lesions to their trainer or coach. Training equipment should be sanitized daily after use and any gear used should be regularly washed with soap and water. Prophylaxis, as discussed above, has been shown to reduce risk of HSV acquisition, prevent recurrence of previous, and outbreak.


In summary, Herpes Gladiatorum is common among wrestlers. It is caused by the HSV1 virus. Diagnosis is clinical with confirmation by microbiology. Treatment is valacyclovir, removal from participation and return to play following governing body guidelines. Prevention is key! There are few complications if managed correctly, but physicians should always be suspicious of herpes keratitis in presentations on the face and perform a thorough eye exam in those athletes.

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