Blake Fagan, MD

A 35-year-old man came into our clinic with a rash that had developed a week earlier after a trip to a North Carolina beach. The rash started on his upper inner arms (not including his axilla) and then developed in his groin, thighs, buttocks, and the tops of his feet. There was no rash on his back, head, or neck. The rash was a maculopapular eruption with some confluence, and it had a discrete distribution in his bathing suit area.

The patient said the rash was very itchy, although it had improved over the past couple of days. He did not have any systemic symptoms and hadn’t used any new soaps or detergents, nor had he recently worn any new clothes. He did note, however, that he’d experienced a similar rash in the past after trips to the beach, although the previous rashes were not as severe.

None of the other family members who’d accompanied him to the beach had developed the rash.

FIGURE
A discrete maculopapular eruption in the bathing suit area

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Seabather’s eruption

The patient was given a diagnosis of seabather’s eruption (SBE), also called seabather’s dermatitis or sea lice. SBE is an intensely itchy papular-erythematous dermatitis that can develop after an individual has been swimming in the ocean.¹

Planula larvae of the scyphomedusae Linuche unguiculata—commonly known as the thimble jellyfish—are to blame for this form of dermatitis.²L unguiculata are most frequently found in the waters of the Caribbean, Gulf of Mexico, southern United States, and South America.¹ Cases of SBE are most common in the spring and summer months, peaking in May.³ Those at highest risk include children, people with a history of SBE, and water sports enthusiasts (eg, surfers).⁴

L unguiculata larvae are small enough that they can make their way through the mesh of swimwear. As the bather gets out of the water, the suit acts as a sieve, with the water draining out and many of the larvae staying behind.¹ Once the jellyfish are pressed against the skin, a defense mechanism is triggered and envenomation occurs.^1,5

As a result, patients will develop rashes not only in areas beneath their swimsuits, but also in the skin folds, such as the axilla, and between the upper thighs. For surfers, the trouble spots are the chest and abdomen—places where the body rubs up against the surfboard.^3,6

Onset does not occur immediately. Rather, it takes several hours for the lesions to develop, and new ones may continue to develop for days.⁵ Immediate stinging sensations are associated with prior cases of SBE and suggest a sensitization to the antigen.³

Not all reactions are the same. Some people will have a severe response, while others appear to be immune.² More extreme systemic symptoms, such as fever, chills, nausea, malaise, sneezing, dyspnea, vomiting, headache, abdominal pain, and diarrhea have been seen in children and in cases of extensive envenomation.^4,6

“Swimmer’s itch” is included in the differential

Other possible causes of pruritic rashes like the one our patient had (TABLE) include:

Cercarial dermatitis, also known as swimmer’s itch, is a maculopapular inflammation characterized by pain, prickling, and pruritus. It develops several hours after bathing in freshwater and is limited to exposed areas of the body. The cause of the dermatitis? The larval trematodes of Shistosoma and Trichobilharzia.⁵

Phytophotodermatitis is an erythematous pruritic inflammation of the skin with vesicles and bullae. The eruption, which is often hyperpigmented, occurs when an individual spends time in the sun after coming into contact with light-sensitive botanicals, such as limes.⁷

Infectious folliculitis is an infection of the hair follicle resulting in the formation of multiple pustules. Pseudomonas aeruginosa folliculitis, often called hot tub folliculitis, may be pruritic and tender.⁷

Grover’s disease is also known as transient acantholytic dermatosis and generally affects middle-aged men. It is a pruritic dermatosis of scaling papules that are distributed along the trunk and can show confluence. Although the cause is unknown, it has been linked with cases of high fever, intense exercise, and significant sun exposure.⁷

Table
The differential for a pruritic, erythematous maculopapular rash^5,7

Treatment usually isn’t needed

SBE usually resolves spontaneously within a week or 2.¹ If treatment is necessary, start with topical corticosteroids and oral antihistamines. If this proves insufficient, move on to oral corticosteroids¹ (strength of recommendation [SOR]: C). To minimize risk, swimmers should remove their bathing suits and shower as soon as possible after leaving the water^4,6 (SOR: C).

Benadryl does the trick
We advised our patient to take diphenhydramine (Benadryl) and the itching went away. We also encouraged him to remove his bathing suit and shower as soon as possible after going in the ocean.

CORRESPONDENCE Blake Fagan, MD, MAHEC Family Medicine Residency Program, 118 W.T. Weaver Boulevard, Asheville, NC 28804; [email protected]

A 35-year-old man came into our clinic with a rash that had developed a week earlier after a trip to a North Carolina beach. The rash started on his upper inner arms (not including his axilla) and then developed in his groin, thighs, buttocks, and the tops of his feet. There was no rash on his back, head, or neck. The rash was a maculopapular eruption with some confluence, and it had a discrete distribution in his bathing suit area.

The patient said the rash was very itchy, although it had improved over the past couple of days. He did not have any systemic symptoms and hadn’t used any new soaps or detergents, nor had he recently worn any new clothes. He did note, however, that he’d experienced a similar rash in the past after trips to the beach, although the previous rashes were not as severe.

None of the other family members who’d accompanied him to the beach had developed the rash.

FIGURE
A discrete maculopapular eruption in the bathing suit area

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Seabather’s eruption

The patient was given a diagnosis of seabather’s eruption (SBE), also called seabather’s dermatitis or sea lice. SBE is an intensely itchy papular-erythematous dermatitis that can develop after an individual has been swimming in the ocean.¹

Planula larvae of the scyphomedusae Linuche unguiculata—commonly known as the thimble jellyfish—are to blame for this form of dermatitis.²L unguiculata are most frequently found in the waters of the Caribbean, Gulf of Mexico, southern United States, and South America.¹ Cases of SBE are most common in the spring and summer months, peaking in May.³ Those at highest risk include children, people with a history of SBE, and water sports enthusiasts (eg, surfers).⁴

L unguiculata larvae are small enough that they can make their way through the mesh of swimwear. As the bather gets out of the water, the suit acts as a sieve, with the water draining out and many of the larvae staying behind.¹ Once the jellyfish are pressed against the skin, a defense mechanism is triggered and envenomation occurs.^1,5

As a result, patients will develop rashes not only in areas beneath their swimsuits, but also in the skin folds, such as the axilla, and between the upper thighs. For surfers, the trouble spots are the chest and abdomen—places where the body rubs up against the surfboard.^3,6

Onset does not occur immediately. Rather, it takes several hours for the lesions to develop, and new ones may continue to develop for days.⁵ Immediate stinging sensations are associated with prior cases of SBE and suggest a sensitization to the antigen.³

Not all reactions are the same. Some people will have a severe response, while others appear to be immune.² More extreme systemic symptoms, such as fever, chills, nausea, malaise, sneezing, dyspnea, vomiting, headache, abdominal pain, and diarrhea have been seen in children and in cases of extensive envenomation.^4,6

“Swimmer’s itch” is included in the differential

Other possible causes of pruritic rashes like the one our patient had (TABLE) include:

Cercarial dermatitis, also known as swimmer’s itch, is a maculopapular inflammation characterized by pain, prickling, and pruritus. It develops several hours after bathing in freshwater and is limited to exposed areas of the body. The cause of the dermatitis? The larval trematodes of Shistosoma and Trichobilharzia.⁵

Phytophotodermatitis is an erythematous pruritic inflammation of the skin with vesicles and bullae. The eruption, which is often hyperpigmented, occurs when an individual spends time in the sun after coming into contact with light-sensitive botanicals, such as limes.⁷

Infectious folliculitis is an infection of the hair follicle resulting in the formation of multiple pustules. Pseudomonas aeruginosa folliculitis, often called hot tub folliculitis, may be pruritic and tender.⁷

Grover’s disease is also known as transient acantholytic dermatosis and generally affects middle-aged men. It is a pruritic dermatosis of scaling papules that are distributed along the trunk and can show confluence. Although the cause is unknown, it has been linked with cases of high fever, intense exercise, and significant sun exposure.⁷

Table
The differential for a pruritic, erythematous maculopapular rash^5,7

Treatment usually isn’t needed

SBE usually resolves spontaneously within a week or 2.¹ If treatment is necessary, start with topical corticosteroids and oral antihistamines. If this proves insufficient, move on to oral corticosteroids¹ (strength of recommendation [SOR]: C). To minimize risk, swimmers should remove their bathing suits and shower as soon as possible after leaving the water^4,6 (SOR: C).

Benadryl does the trick
We advised our patient to take diphenhydramine (Benadryl) and the itching went away. We also encouraged him to remove his bathing suit and shower as soon as possible after going in the ocean.

CORRESPONDENCE Blake Fagan, MD, MAHEC Family Medicine Residency Program, 118 W.T. Weaver Boulevard, Asheville, NC 28804; [email protected]

A 35-year-old man came into our clinic with a rash that had developed a week earlier after a trip to a North Carolina beach. The rash started on his upper inner arms (not including his axilla) and then developed in his groin, thighs, buttocks, and the tops of his feet. There was no rash on his back, head, or neck. The rash was a maculopapular eruption with some confluence, and it had a discrete distribution in his bathing suit area.

The patient said the rash was very itchy, although it had improved over the past couple of days. He did not have any systemic symptoms and hadn’t used any new soaps or detergents, nor had he recently worn any new clothes. He did note, however, that he’d experienced a similar rash in the past after trips to the beach, although the previous rashes were not as severe.

None of the other family members who’d accompanied him to the beach had developed the rash.

FIGURE
A discrete maculopapular eruption in the bathing suit area

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Seabather’s eruption

The patient was given a diagnosis of seabather’s eruption (SBE), also called seabather’s dermatitis or sea lice. SBE is an intensely itchy papular-erythematous dermatitis that can develop after an individual has been swimming in the ocean.¹

Planula larvae of the scyphomedusae Linuche unguiculata—commonly known as the thimble jellyfish—are to blame for this form of dermatitis.²L unguiculata are most frequently found in the waters of the Caribbean, Gulf of Mexico, southern United States, and South America.¹ Cases of SBE are most common in the spring and summer months, peaking in May.³ Those at highest risk include children, people with a history of SBE, and water sports enthusiasts (eg, surfers).⁴

L unguiculata larvae are small enough that they can make their way through the mesh of swimwear. As the bather gets out of the water, the suit acts as a sieve, with the water draining out and many of the larvae staying behind.¹ Once the jellyfish are pressed against the skin, a defense mechanism is triggered and envenomation occurs.^1,5

As a result, patients will develop rashes not only in areas beneath their swimsuits, but also in the skin folds, such as the axilla, and between the upper thighs. For surfers, the trouble spots are the chest and abdomen—places where the body rubs up against the surfboard.^3,6

Onset does not occur immediately. Rather, it takes several hours for the lesions to develop, and new ones may continue to develop for days.⁵ Immediate stinging sensations are associated with prior cases of SBE and suggest a sensitization to the antigen.³

Not all reactions are the same. Some people will have a severe response, while others appear to be immune.² More extreme systemic symptoms, such as fever, chills, nausea, malaise, sneezing, dyspnea, vomiting, headache, abdominal pain, and diarrhea have been seen in children and in cases of extensive envenomation.^4,6

“Swimmer’s itch” is included in the differential

Other possible causes of pruritic rashes like the one our patient had (TABLE) include:

Cercarial dermatitis, also known as swimmer’s itch, is a maculopapular inflammation characterized by pain, prickling, and pruritus. It develops several hours after bathing in freshwater and is limited to exposed areas of the body. The cause of the dermatitis? The larval trematodes of Shistosoma and Trichobilharzia.⁵

Phytophotodermatitis is an erythematous pruritic inflammation of the skin with vesicles and bullae. The eruption, which is often hyperpigmented, occurs when an individual spends time in the sun after coming into contact with light-sensitive botanicals, such as limes.⁷

Infectious folliculitis is an infection of the hair follicle resulting in the formation of multiple pustules. Pseudomonas aeruginosa folliculitis, often called hot tub folliculitis, may be pruritic and tender.⁷

Grover’s disease is also known as transient acantholytic dermatosis and generally affects middle-aged men. It is a pruritic dermatosis of scaling papules that are distributed along the trunk and can show confluence. Although the cause is unknown, it has been linked with cases of high fever, intense exercise, and significant sun exposure.⁷

Table
The differential for a pruritic, erythematous maculopapular rash^5,7

Treatment usually isn’t needed

SBE usually resolves spontaneously within a week or 2.¹ If treatment is necessary, start with topical corticosteroids and oral antihistamines. If this proves insufficient, move on to oral corticosteroids¹ (strength of recommendation [SOR]: C). To minimize risk, swimmers should remove their bathing suits and shower as soon as possible after leaving the water^4,6 (SOR: C).

Benadryl does the trick
We advised our patient to take diphenhydramine (Benadryl) and the itching went away. We also encouraged him to remove his bathing suit and shower as soon as possible after going in the ocean.

CORRESPONDENCE Blake Fagan, MD, MAHEC Family Medicine Residency Program, 118 W.T. Weaver Boulevard, Asheville, NC 28804; [email protected]

Evidence summary

A systematic review of the literature on PPE identified 310 studies of athletes age <36 years. The authors searched multiple electronic databases and reviewed the bibliographies of retrieved articles but did not perform hand searches of journals or contact authors directly. The review did not find any prospective cohort or randomized trials addressing the effectiveness of clinical PPE. The 5 studies that assessed the format of the PPE concluded that it is not adequately standardized, does not consistently address the American Heart Association (AHA) recommendations for cardiovascular screening and exam, and is administered by a variety of health care professionals, some without proper training.¹

Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden cardiac arrest within 6 hours of a previously witnessed state of normal health.² Such events occur in about 1 in 200,000 high school athletes per academic year (about 16 deaths in the US annually). Detection of cardiovascular abnormalities that may cause morbidity or mortality is difficult. A case series reviewed 158 sudden deaths that occurred in trained athletes in the US from 1985 to 1995. The athletes were identified from news accounts, the National Center for Catastrophic Sports Injury Registry, and informal communications and reports. The authors interviewed families, witnesses, and coaches, and they analyzed postmortem information. Of the 115 athletes who had a standard preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular disease. The cardiovascular abnormality responsible for sudden death was prospectively identified in only 1 athlete.³

PPE does not accurately identify student athletes with exercise-induced bronchospasm (EIB). Of the studies on EIB, the best was a prospective cross-sectional study of 352 adolescents from 3 suburban Washington state schools. The students completed a 14-item EIB questionnaire, had a physical exam, and underwent a 7-minute exercise challenge spirometry. Complete data were available for 256 of the students. EIB was diagnosed by spirometry in 9.4% of the athletes. No student had EIB detected solely by physical exam. Using a cutoff of 2 positive questions, the questionnaire had a sensitivity of 71% and a specificity of 47%, with a negative and positive predictive value of 6% and 12%, respectively. This study concluded that EIB occurs frequently in adolescent athletes, but screening by physical exam and medical history does not accurately detect it.⁴

PPEs are not able to predict which student athletes will experience an orthopedic injury, and no controlled studies have been done to determine whether PPE prevents or reduces the severity of orthopedic injuries. A study surveyed 1204 student athletes (aged 13–20 years) from Richmond County, Georgia, who had a standardized PPE before participating in sports. The questionnaire was administered via mail or telephone and inquired about injuries sustained after the PPE. The response rate to the survey was 56%. The study found that a history of knee or ankle injury and abnormal findings on exam in male athletes slightly increased the likelihood of repeated injury of the same joint. However, the sensitivities of history or physical exam for ankle or knee injuries were all <25%.⁵

Recommendations from others

The AHA recommends a national standard for PPE and that screening should be mandatory for all high school and college athletes before participation in organized sports, with screening repeated every 2 years, and an interim history obtained during the intervening years. Specific items are given in the TABLE.⁶

In 2004, the American Academy of Family Physicians, along with the American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, published recommendations for PPEs. They suggested a detailed history (consisting of a 16-point questionnaire incorporating AHA recommendations for cardiovascular screening), limited medical exam, and a detailed musculoskeletal exam evaluating strength, flexibility, and stability of major joints.⁷

TABLE
AHA recommendations for preparticipation exams

Evidence summary

A systematic review of the literature on PPE identified 310 studies of athletes age <36 years. The authors searched multiple electronic databases and reviewed the bibliographies of retrieved articles but did not perform hand searches of journals or contact authors directly. The review did not find any prospective cohort or randomized trials addressing the effectiveness of clinical PPE. The 5 studies that assessed the format of the PPE concluded that it is not adequately standardized, does not consistently address the American Heart Association (AHA) recommendations for cardiovascular screening and exam, and is administered by a variety of health care professionals, some without proper training.¹

Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden cardiac arrest within 6 hours of a previously witnessed state of normal health.² Such events occur in about 1 in 200,000 high school athletes per academic year (about 16 deaths in the US annually). Detection of cardiovascular abnormalities that may cause morbidity or mortality is difficult. A case series reviewed 158 sudden deaths that occurred in trained athletes in the US from 1985 to 1995. The athletes were identified from news accounts, the National Center for Catastrophic Sports Injury Registry, and informal communications and reports. The authors interviewed families, witnesses, and coaches, and they analyzed postmortem information. Of the 115 athletes who had a standard preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular disease. The cardiovascular abnormality responsible for sudden death was prospectively identified in only 1 athlete.³

PPE does not accurately identify student athletes with exercise-induced bronchospasm (EIB). Of the studies on EIB, the best was a prospective cross-sectional study of 352 adolescents from 3 suburban Washington state schools. The students completed a 14-item EIB questionnaire, had a physical exam, and underwent a 7-minute exercise challenge spirometry. Complete data were available for 256 of the students. EIB was diagnosed by spirometry in 9.4% of the athletes. No student had EIB detected solely by physical exam. Using a cutoff of 2 positive questions, the questionnaire had a sensitivity of 71% and a specificity of 47%, with a negative and positive predictive value of 6% and 12%, respectively. This study concluded that EIB occurs frequently in adolescent athletes, but screening by physical exam and medical history does not accurately detect it.⁴

PPEs are not able to predict which student athletes will experience an orthopedic injury, and no controlled studies have been done to determine whether PPE prevents or reduces the severity of orthopedic injuries. A study surveyed 1204 student athletes (aged 13–20 years) from Richmond County, Georgia, who had a standardized PPE before participating in sports. The questionnaire was administered via mail or telephone and inquired about injuries sustained after the PPE. The response rate to the survey was 56%. The study found that a history of knee or ankle injury and abnormal findings on exam in male athletes slightly increased the likelihood of repeated injury of the same joint. However, the sensitivities of history or physical exam for ankle or knee injuries were all <25%.⁵

Recommendations from others

The AHA recommends a national standard for PPE and that screening should be mandatory for all high school and college athletes before participation in organized sports, with screening repeated every 2 years, and an interim history obtained during the intervening years. Specific items are given in the TABLE.⁶

In 2004, the American Academy of Family Physicians, along with the American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, published recommendations for PPEs. They suggested a detailed history (consisting of a 16-point questionnaire incorporating AHA recommendations for cardiovascular screening), limited medical exam, and a detailed musculoskeletal exam evaluating strength, flexibility, and stability of major joints.⁷

TABLE
AHA recommendations for preparticipation exams

Evidence summary

A systematic review of the literature on PPE identified 310 studies of athletes age <36 years. The authors searched multiple electronic databases and reviewed the bibliographies of retrieved articles but did not perform hand searches of journals or contact authors directly. The review did not find any prospective cohort or randomized trials addressing the effectiveness of clinical PPE. The 5 studies that assessed the format of the PPE concluded that it is not adequately standardized, does not consistently address the American Heart Association (AHA) recommendations for cardiovascular screening and exam, and is administered by a variety of health care professionals, some without proper training.¹

Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden cardiac arrest within 6 hours of a previously witnessed state of normal health.² Such events occur in about 1 in 200,000 high school athletes per academic year (about 16 deaths in the US annually). Detection of cardiovascular abnormalities that may cause morbidity or mortality is difficult. A case series reviewed 158 sudden deaths that occurred in trained athletes in the US from 1985 to 1995. The athletes were identified from news accounts, the National Center for Catastrophic Sports Injury Registry, and informal communications and reports. The authors interviewed families, witnesses, and coaches, and they analyzed postmortem information. Of the 115 athletes who had a standard preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular disease. The cardiovascular abnormality responsible for sudden death was prospectively identified in only 1 athlete.³

PPE does not accurately identify student athletes with exercise-induced bronchospasm (EIB). Of the studies on EIB, the best was a prospective cross-sectional study of 352 adolescents from 3 suburban Washington state schools. The students completed a 14-item EIB questionnaire, had a physical exam, and underwent a 7-minute exercise challenge spirometry. Complete data were available for 256 of the students. EIB was diagnosed by spirometry in 9.4% of the athletes. No student had EIB detected solely by physical exam. Using a cutoff of 2 positive questions, the questionnaire had a sensitivity of 71% and a specificity of 47%, with a negative and positive predictive value of 6% and 12%, respectively. This study concluded that EIB occurs frequently in adolescent athletes, but screening by physical exam and medical history does not accurately detect it.⁴

PPEs are not able to predict which student athletes will experience an orthopedic injury, and no controlled studies have been done to determine whether PPE prevents or reduces the severity of orthopedic injuries. A study surveyed 1204 student athletes (aged 13–20 years) from Richmond County, Georgia, who had a standardized PPE before participating in sports. The questionnaire was administered via mail or telephone and inquired about injuries sustained after the PPE. The response rate to the survey was 56%. The study found that a history of knee or ankle injury and abnormal findings on exam in male athletes slightly increased the likelihood of repeated injury of the same joint. However, the sensitivities of history or physical exam for ankle or knee injuries were all <25%.⁵

Recommendations from others

The AHA recommends a national standard for PPE and that screening should be mandatory for all high school and college athletes before participation in organized sports, with screening repeated every 2 years, and an interim history obtained during the intervening years. Specific items are given in the TABLE.⁶

In 2004, the American Academy of Family Physicians, along with the American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, published recommendations for PPEs. They suggested a detailed history (consisting of a 16-point questionnaire incorporating AHA recommendations for cardiovascular screening), limited medical exam, and a detailed musculoskeletal exam evaluating strength, flexibility, and stability of major joints.⁷

TABLE
AHA recommendations for preparticipation exams