Allergic

skin conditions in athletes

Louis J Holtzhausen, MB ChB, M Phil (Sports Medi-

cine), FAFP(SA)
Program Director: Sports Medicine, School of Medicine, University of the Free State, Bloemfontein, South
Africa
ABSTRACT
Allergic skin conditions occur more commonly in athletes than in the general population, as a result of the
physical and psychological demands of sport as well
as increased exposure to irritants and allergens. A
good understanding of causes and mechanisms of
skin allergies is required for optimal management.
Information from the literature used in this review is
mainly from case studies and case series, but also
from clinical trials and earlier reviews.
Urticaria is the consequence of type I allergic reactions and can be associated with exercise-induced
angio-oedema and anaphylaxis. Causative factors,
management and prevention of urticaria in the athletic population are discussed. The non-allergic urticarias, caused by physical stimuli such as heat, cold,
exertion, mechanical stimulation of the skin, water
and radiation are described. Allergic urticarias are
uncommon in athletes. The two contact sensitisation syndromes that occur in athletes are allergic
contact dermatitis (ACD) associated with type IV allergic reactions, and irritant contact dermatitis (ICD).
Specific irritants and allergens associated with types
of sport are presented. Stings, envenomations and
infestations also occur in the athletic population. Selected conditions, especially those associated with
water sports, are discussed. Optimal management
and prevention of allergic skin conditions in athletes
can prevent poor performance, physical and psychological morbidity, and mortality.

INTRODUCTION
Allergic conditions are very common and affect 25-30%
of the population, resulting in significant morbidity, absenteeism, loss of quality of life and even death.1 Skin
allergies have a high incidence, constituting 42% of occupational allergic diseases in certain countries.2,3 Skin
functions and adaptations including body temperature
homeostasis and protection from external stimuli are
essential for proper functioning of the body, as well as
for optimal athletic performance. The skin is challenged
during certain sport activities. Exercise induces alterations in the hydrolipid film of the skin and increases skin
pH as a result of associated changes in skin buffering
systems. Increased sweating and reduced opportunity
for evaporation due to protective clothing modify the
defensive capacity of the skin by changing the nature
of the hydrolipid barrier and surface flora.4 In addition,
exposure to sun and other atmospheric conditions triggers a series of events in the skin, including dissolution
of molecular bonds, formation of oxygen free radicals,
production of peroxidase, and denaturation of certain
protein structures.5 Furthermore, frequent washing and

the use of topical substances alter the normal skin homeostasis in athletes, increasing the possibility of development of irritant contact dermatitis (ICD) or allergic
contact dermatitis (ACD).6 It has also been postulated
that mental and physical stress can increase the incidence of skin disorders, including certain allergic conditions.7
The interaction of sport and allergy has attracted attention, especially regarding the influence of allergy and
its management on performance. However, the effect
of exposure of athletes to possible allergens in sports
equipment, activities, venues and other sources is just
as important for clinicians treating athletes, in order to
understand hypersensitivity caused by sporting activity.
Allergic skin conditions will be discussed in three major
categories: (i) urticaria; (ii) contact sensitisation; and (iii)
stings, envenomations and infestations.8

URTICARIA
Exercise-associated urticaria is part of a continuum of
urticaria, angio-oedema and anaphylaxis. Angio-oedema
and anaphylaxis are discussed elsewhere in this edition.
Athletes presenting with urticaria or angio-oedema with
or without anaphylactic reaction may be responding to
allergic triggers or non-allergic physical stimuli.8 The essence of this review is not focused on the non-allergic
conditions; however, as it is often difficult to identify
the cause of urticaria, these must be considered in
diagnosis and management of these patients and will
therefore be discussed briefly.

Non-allergic urticaria
Non-allergic urticaria, also known as physical urticaria,
resulting from several physical causes, represents less
than 3% of all urticarias. Conversely, in the athletic population the incidence of non-allergic urticaria increases
to 15%.9 Causative stimuli include heat, cold, exertion,
emotions, mechanical (stroke, pressure, vibration), water and radiation.8,10
Cholinergic urticaria is the most common of the nonallergic urticarias, affecting 15% of the population.2
It can result from a rapid rise in body temperature
from a combination of exercise, sweating and/or
hot showers.8 It may also be exacerbated by anxiety.2 The typical clinical presentation is with burning,
warmth and irritation of the skin, followed by intense
pruritus and the appearance of typical urticarial lesions. Cholinergic urticaria is characterised by small
wheals (1-4 mm), surrounded by large erythematous
areas, occurring anywhere on the body. It is rarely
associated with systemic symptoms and measurable mediator release.2,8,10 Lesions lasting longer
than 24 hours warrant specialist dermatological evaluation. The diagnosis of cholinergic urticaria can be
confirmed by passive heating of the patient and reproduction of symptoms and signs, for example in a
sauna.10 Regular use of non-sedating antihistamines
or hydroxizine can treat and prevent cholinergic
urticaria.2,11,12 Protease inhibitors can also be used.
Prevention may be accomplished with a programme
of incrementally increasing activity levels to induce

Correspondence: Dr LJ Holtzhausen, Internal Box 14, University of the Free State, PO Box 339, Bloemfontein 9300. E-mail:
geslh@ufs.ac.za

72

Current Allergy & Clinical Immunology, June 2010 Vol 23, No. 2

tolerance.11,12 Treatment and prevention are often

not fully successful.2
Cold urticaria occurs in swimmers and outdoor winter athletes and is associated rather with sudden
drops in temperature than with cold per se. Loss of
consciousness associated with cold urticaria is of serious concern.13
Pressure-related angio-oedema occurs during activities of sustained application of pressure, for example gripping of handles. Delayed-pressure urticaria
occurs 2 or more hours after application of pressure
to the skin.2
Solar urticaria develops within minutes of exposure
to natural or artificial ultraviolet radiation, and clears
within an hour.12
Pure aquagenic urticaria is rare and develops after
contact with water regardless of its temperature,
which distinguishes it from the very similar cold or
cholinergic urticarias.11 One case reported a more
severe response from sea water than fresh water.8
Traumatic plantar urticaria is a self-limiting condition
that has previously been described on the soles of
runners and young basketball players feet. It presents with plantar pain that develops over days. Exquisitely tender, well-defined, small, erythematous
to violaceous macules and papules appear. It can
only be distinguished from neutrophilic hidradenitis
by biopsy.10
Dermatographism is another non-allergic form of urticaria that develops on skin, typically beneath protective clothing. Erythematous, oedematous plaques
develop on skin surfaces that have been rubbed or
scratched. Diagnosis is confirmed by stimulating the
skin with a moderate stroking stimulus, usually on
the athletes back and observing the development of
a typical wheal.14
Non-allergic urticaria in sport is not confined to athletes, and has been described in a football spectator who developed an urticarial rash on his trunk
and limbs while watching two World Cup games on
television in which the English team was performing
poorly!15

Allergic urticaria
Allergic urticaria has been described in a small number
of reports, as a different entity to contact sensitisation/
contact dermatitis.8 Allergic urticaria was demonstrated
by the presence of urticaria after exposure to swimming
pool chlorine, raw fish handling and horse saliva, and it
is associated with type I allergic reactions.16-18
Typical urticareal wheals can be seen in Figure 1.
Management of the urticarias is based on accurate
identification of the cause of the reaction and provision
of adequate education in the pathogenesis of the condition. There may be a refractory period after certain
physical urticarias, which the athlete can use to his/her
advantage. Patients at risk of cold urticaria should be
warned of the associated collapse and risk of drowning.
It must also be emphasised that urticaria can develop
into life-threatening angio-oedema and anaphylaxis.
Susceptible athletes should never train alone. Symptom management and prevention, albeit often incomplete, is with non-sedating antihistamines.2
Exercise after receiving allergen immunotherapy injections should be avoided to prevent increased allergen
dissemination and a systemic allergic response.8

CONTACT SENSITISATION
The exact prevalence of contact dermatitis (or contact
eczema) in the athletic population is not known, but

Fig. 1. Urticaria.
the prevalence of dermatitis in the UK is estimated at
about 20%.19,20 Numerous case reports in the literature
suggest that it is a common occurrence in the athletic
population.12 Two types of contact dermatitis should be
distinguished. Allergic contact dermatitis (ACD) is a typical type IV delayed-type allergic reaction to a relevant
substance, usually a chemical, that acts as a hapten.
Irritant contact dermatitis (ICD), on the other hand, is
a cutaneous reaction to an irritant which can occur in
all athletes and is not limited to atopic individuals. The
only rate-limiting step in ICD is the concentration of the
irritant.10,21

Allergic contact dermatitis (ACD)

ACD presents as well-defined, erythematous, vesicular, variably crusted or eroded, linear or shaped plaques.
These lesions are usually confined to the area of contact between the skin and the allergen.2,12 The typical
location, morphology and history make the diagnosis
relatively easy. If necessary, the diagnosis can be confirmed with a positive patch test of the causative chemical, which will be negative in the event of urticarias or
physical irritants.2 Typical examples of causes of ACD
are topical analgesics and adhesive tape, as well as rubber in shoes, masks and equipment handles.

Irritant contact dermatitis (ICD)

ICD presents mostly as a clearly demarcated area of
erythematous, occasionally vesicular, mildly scaling
plaques in the distribution of exposure to the irritant.
Chronic irritant exposure can result in lichenification
(thickening) of the skin. ICD develops rapidly after exposure, as the development of symptoms is not related to
a delayed-type hypersensitivity reaction. The diagnosis
of ICD can be confirmed with negative potassium hydroxide and patch tests. Typical examples of causative
factors of ICD are calcium oxide in field-marking chalk,
fibreglass in hockey sticks, and even chemicals exuded
from leaking chemical ice packs.12

Similarities
The clinical presentations of ACD and ICD are very similar and it is often not possible to clinically distinguish
between the two conditions.21 The management of
both conditions, however, is similar and includes avoid-

Current Allergy & Clinical Immunology, June 2010 Vol 23, No. 2

73

ance of the causative factor and use of topical corticosteroids. ACD and ICD can both cause severe exudates
with yellow, crusted plaques which should be distinguished from impetigo.10
For organisational purposes the contact sensitivities
have been categorised according to types of sport.
Even though the majority of conditions mentioned are
ACD, a number of cases of ICD may have been included
because of difficulty in differentiation between the two
conditions. It will matter little for the physician, but a list
of possible causative materials of skin sensitisation will
be of tremendous assistance.8

Water sports: swimming, diving, snorkeling, SCUBA, fishing

The two major sources of allergens or irritants for
swimmers are (i) materials used to treat or clean swimming pools or equipment, and (ii) gear, such as goggles,
masks and wet suits. Cleaning materials that cause allergy or irritation include bromine-containing spa-pool
cleaners and halogen/chlorine-containing swimming
pool disinfectants.22,23 Equipment disinfectants containing dodecyl diamino ethyl glycine, a disinfectant
known to be prone to sensitising the skin, has been
shown to cause ACD in a diver.24 Goggles with black
foam-rubber seals are a common cause of ACD, from
a number of possible rubber constituents and processing materials.25-28 Other watersport equipment that
might cause an allergic reaction are nose clips, fins and
mouthpieces.29 It has been proposed that allergies to
facial masks may become less common as less allergenic plastics are becoming more popular materials in
the manufacturing of masks.8 The most common cause
of ACD in divers are allergens in wetsuit material such
as neoprene. Prominent allergens in wetsuit material
are the thioureas used as rubber accelerators or nylon
glues, thiorams and mercaptobenzothiazole used as
rubber-processing agents, and nickel used as an agent
in wetsuit dye.6,30-32 Typical contact dermatitis to swimwear is shown in Figure 2.
In sports fishermen, cases of ACD have been reported resulting from maggots and dyes used to colour
maggots.33,34 Contact and systemic sensitivity to fish
per se is well known.17

Outdoor and team sports

Many case reports of contact dermatitis in outdoor
sports, caused by various allergens exist in the literature.35 The number of case reports in the literature
suggests a high prevalence. In order to organise the
search for an allergen for the clinician, contact dermatitis in outdoor and team sports will be discussed under
allergies to: (i) creams, topical medication and taping;
(ii) protective gear and clothing; (iii) equipment; and (iv)
environmental allergens.
Topical application of creams, gels and sprays is common in sport. Contact dermatitis to analgesic and antiinflammatory creams has been reported from ingredients such as benzocaine, eucalyptol oil, salicylate and
methyl salicylate, lanolin, arnica, palmitoyl, collagen,
amino acids and others.6,36,37 Colophony (or rosin), a
natural resinous material derived from Pinaceae (pine)
oil, is widely used in adhesives, cosmetics, lacquers
and other industrial products. It is a common cause of
contact and systemic allergy, which can be severe.38 In
athletes it has been shown to cause ACD to gripping
products in bowls, sports taping, and commercial topical ketoprofen patches.39-41 It is interesting to note one
study that reported much reduced allergic reactions to
colophony in adhesive tape when combined correctly
with zinc oxide, which is also a known allergen. In the
same study, a much lower reactivity to abeitic acid, an
ingredient of colophony, was demonstrated to pure
forms of the acid as opposed to the more commonly
used less pure forms.40 Formaldehyde resins, including phenol-formaldehyde and para-tertiary butylphenolformaldehyde are heat resistant, and have considerable
adhesive properties. They are used in the manufacturing of neoprene adhesives, sports taping, and other
domestic products. Both forms have been shown to
cause contact dermatitis in athletes.42,43 Contact and
photocontact sensitivity to various ingredients in sunscreens have been shown to cause ACD.44-46
Allergies to protective gear and clothing in land and team
sports include allergies to latex products, neoprene, epoxy resin, nickel, phenylenediamine, theoureas and the
ingredients of certain dyes. The allergens are found in
shoes, protective helmets, different protective guards
and pads and clothing.6,8,43,47
Exposure to sports equipment can also cause allergies
in athletes. Apart from rubber products discussed earlier, allergies have also been recorded from epoxy resin
in racquet handles and palladium in metal weights.29,48
Environmental contact dermatitis has been described
in athletes allergic to poison ivy (Rhus), poison sumac
and other plants.49 Many skin reactions to grass are
due to skin irritation, but ACD to grass types has been
described and is likely to be more prevalent than currently shown in the literature.50 Prolonged contact to
environmental allergens and disruption of skin barriers
may expose field and extreme cross-country athletes
to more severe forms of ACD and ICD than the general
population.

Indoor sports

Fig. 2. Contact dermatitis to swimwear.

74

In indoor sports, ACD to colophony in fencing, Sudan IV

red dye in a judo carpet, and epoxy resin in a billiard cue
have been described.6,51,52
The mainstay of management of ICD and ACD is avoidance of the irritant or allergen. This can be accomplished
by: (i) specific identification and avoidance of the allergen by patch testing of the suspected allergen or standard series of allergens; and (ii) protection of the skins
lipid barrier, by avoiding irritants, strong cleansers, environmental factors such as wind, sun, low humidity, sudden temperature changes, and appropriate use of skin
Current Allergy & Clinical Immunology, June 2010 Vol 23, No. 2

emollients and soap substitutes. Emollients provide a

surface film of lipids that restores some of the barrier
function of the skin. This oily layer traps water under
the stratum corneum, and reduces epidermal water
loss.20,53 Patients should be advised to apply emollients
in the general direction of hair growth, to avoid folliculitis.53 Barrier creams are used to prevent contact with
irritants or allergens but their value is questionable.20,21
Topical corticosteroids are used to treat ICD and ACD
that do not respond to emollient use, and for acute
exacerbations. Ointments are generally preferable to
creams, to produce a deeper, more prolonged emollient
effect and to increase the efficacy of the corticosteroid.
Use is recommended for short spells of 3-7 days, of the
least potent corticosteroid the condition will respond to.
After treatment of the acute incident, only emollients
are required to maintain control. If the condition does
not improve after 3-7 days of steroid use, the diagnosis
should be reassessed.20,21 A rapid burst of oral steroids
may be necessary for severe outbreaks, but is rarely
required.10,12 Because of the fact that patients requiring treatment might be competitive athletes, physicians
should take care to avoid medications that are banned
by sport governing bodies and the World Anti-Doping
Agency (WADA) and make use of the Therapeutic Use
Exemption (TUE) guidelines if such pharmacological
agents are used. A list of medications requiring TUE
and guidelines for application can be found at www.
wada-ama.org.

STINGS, ENVENOMATIONS AND INFESTATIONS

Outdoor athletes on land and in water are exposed to
potential stings, bites and infestations from insects,
other poisonous creatures and parasites. Skin conditions that develop in open fresh or sea water are of
particular interest to the open-water athlete. Typically,
the initial response to violation of the skin is toxic or
mechanical, with an allergic reaction enhancing or succeeding the initial pattern.8
Swimmers itch (clamdiggers itch, bathers itch) has a
worldwide distribution, but occurs especially in temperate and subtropical areas.54 This condition is a schistosomic infestation that affects water birds and snails in
fresh or brackish water. Free-swimming cercaria leave
the host snail to find a bird to complete their life cycle.
Incidental infestation of human skin occurs, where they
do not survive but cause a local allergic response. The
clinical presentation is a burning sensation after water
on the skin has dried, followed by mild pruritus. Erythema and progressive pruritus follows, with a maculopapular rash following several hours later. The rash
may progress to a blister or pustule. Bare skin is more
commonly affected. The rash indicates the allergic reaction and lasts a week or more. Previously sensitised
individuals will experience a quicker and more vigorous
reaction.54
Seabathers eruption occurs in saltwater bathers and
has been described off the coast of Florida, Long Island, and in the Caribbean. The two infesting agents
have recently been identified as jellyfish: the thimble
jellyfish Linuche unguiculata, and the sea anemone Edwardsiella lineata.55 Larvae of the organisms possess
nematocysts, or tiny spring-loaded venom injectors.
The larvae get trapped in swimwear. They discharge
the venom when stimulated mechanically or osmotically, often after the swimmer has left the water and the
swimwear has dried. The typical clinical presentation is
an erythematous macular or papular dermatitis, associated with severe pruritus, which occurs in skin covered
by a bathing suit. Associated urticaria has been reported.56 The eruption is often self-limiting, but treatment
in severe cases is with antihistamines and antipruritic

agents, topical corticosteroids, or systemic steroids for

prolonged cases. Since the venom is antigenic, repeat
exposures can cause more severe symptoms. Prevention of the condition includes avoiding water known to
contain larvae, avoiding wearing T-shirts when swimming, and the use of suntan lotion.55
Seabathers eruption should not be confused with the
very common jellyfish sting which is caused by direct
contact with nematocysts on the jellyfish itself. An
estimated 150 million people worldwide are exposed
annually to jellyfish. Jellyfish stings cause local pain
with inflammation of the skin, and may cause local or
systemic allergic responses, especially in previously
sensitised persons. Contact dermatitis from jellyfish
exposures has also been reported.57 The management
of these is similar to other stings. An effective topical
jellyfish-sting-inhibiting barrier cream has been recently
described.58

CONCLUSION
Allergic skin conditions are common in the general population, and significantly more common in the athletic
population. Not only can allergic skin conditions affect
performance and training schedules, but they can have
serious medical consequences. Furthermore, skin afflictions are often visible and can contribute to personal
and social issues for the patient. It is therefore important for the physician treating athletes at any level to
have a sound understanding of allergic skin conditions
and to address them appropriately.
The cornerstone of management of these conditions is
to identify the causative factor as specifically as possible and to distinguish between a physical irritant, type I,
type IV or other allergen, or non-dermatological causes.
Because many skin allergies are permanent or recurrent conditions and will need ongoing management of
recurrence and/or increased severity, patient education
about the pathogenesis, prevention and treatment is
essential. It is also important to empower patients to
prevent and manage serious systemic complications
without immediate medical assistance. Early, meticulous diagnosis, management and prevention can be
very rewarding and can prevent poor athletic performance, morbidity and even death.
Declaration of conflict of interest
The author declares no conflict of interest.

Acknowledgement
Photographs courtesy of Prof W Sinclair, Department of
Dermatology, University of the Free State.

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