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Herpes Gladiatorum

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Other Names

  • HSV 1
  • HSV 2
  • Herpes Simplex Virus
  • Herpes rugbiorum
  • Scrumpox (after rugby football)
  • Wrestler's herpes
  • Mat pox (after wrestling)


  • This page refers to Herpes Gladiatorum (HG), a viral infection causing cutaneous non-genital herpes seen in athletes


  • Originally termed herpes gladiatorum (HG) by Selling and Kibrick in 1964 (need citation)
  • Term first widely used when a wrestling camp had 60/175 wrestlers contract the virus, forcing closure of the camp in 1989[1]


  • Virology
    • In wrestling, 94% to 97% of HSV infections are caused by type 1 infection[2]
    • 29% to 30% of high school wrestlers are infected or colonized with HSV, but only 3% are aware they carry the virus[3]
  • Incidence
    • Estimated that 20% to 40% of collegiate wrestlers will suffer an outbreak of HG each year[4]
    • Up to 87.4% of HSV outbreaks are subclinical and go unnoticed[5]


Primary herpes gladiatorum. Note multiple areas of involvement and regional adenopathy.[6]
  • General
    • Occurs due to cutaneous inoculation with HSV1
    • Variable presentation, practitioner unfamiliarity often leads to misdiagnosis
    • The face is involved in more than 70% of herpes outbreaks in wrestling
  • Outbreaks
    • Although up to 30% of high school athletes carry the virus, only 3% are aware[3]
    • For this reason, large outbreaks seem to occur for unknown reasons
    • Subsequently, there may be lack of proper suspicion when such outbreaks do develop
  • Diagnosis
    • Often missed by physicians
    • One study estimated that the correct diagnosis was made only 10% of the time on initial presentation[7]


Recurrent herpes gladiatorum[6]
  • Skin-to-skin contact
    • Transmission is almost exclusively from direct skin-to-skin contact.
    • Increases risk of traumatic inoculation
    • Sports with prolonged skin to skin contact include wrestling, rugby
  • Non-contributory
    • Training mats and other fomites (need citation)


  • Inoculation[8]
    • Transmitted via viral replication in ganglia and spread along sensory nerve tissue
    • Multiple dermatomes can be involved, may be bilateral
    • There is a 4 to 11 day incubation period
    • Prodrome of hyperesthesia and paresthesia follows incubation
    • No systemic signs are present at this time
  • Rash
    • Papulovesicular rash develops within 2 days, appears in clusters
    • May coalesce to form plaques with surrounding erythema, edema
    • Crusts develop
    • Healing begins within 10 days of onset without hyperpigmentation, scarring
    • Constitutional symptoms (low-grade fever, chills, malaise, and anorexia, headache, tender regional lymphadenopathy) often accompany primary infection

Associated Conditions

Risk Factors

  • Sports
    • Wrestlers[9]
    • Rugby
  • Underlying skin conditions
  • Eczema

Differential Diagnosis

Clinical Features

  • History
    • The face is involved more than 70% of the time (wrestling)
    • The rest of the body makes up the remaining 30%
    • Primary HG
      • Typically presents with systemic symptoms (malaise, low-grade fever, sore throat, lymphadenopathy, headache)
      • 1-2 days later, 1-2 mm maculopapular vesicles will coalesce with minimally reddened base
      • 90% to 93% of infections will occur within 8 days of exposure[2]
      • Lesions typically affect dominant hand, side of head of preferred tie position (wrestling)
    • Secondary HG
      • Fewer vesicles, outbreaks are shorter, fewer systemic symptoms
      • Reoccur, in the same dermatomal or peripheral nerve pattern
  • Physical Exam
    • Inspect oral mucosa for evidence of gingivostomatitis
    • Ophthalmologic exam for ocular herpes presenting as acute, follicular conjunctivitis
    • Herpetic Sycosis: lesions seen in a beard distribution from autoinoculation while shaving.


Herpes Gladitorum of the Head, Face and Scalp[10]


  • Direct microbiology for HSV 1, HSV 2 recommended
    • Examples: Viral culture, HSV polymerase chain reaction
    • Culture is often cheaper, PCR is more rapid
    • Often confused with other skin infections
    • Help distinguish herpes gingivostomatitis and sycosis from other causes of pharyngitis, folliculitis
    • Tzank smear is no longer favored due to poor sensitivity, specificity
  • Serology
    • Limited clinical value due to high rates of positivity, low rates of active disease
    • Commonly lags behind clinical infection
    • Direct microbiologic testing of active lesions is preferred over serologic testing


  • Not applicable



  • General treatment principles[11]
    • Athletes are treated with oral antivirals, which speeds resolution of symptoms
    • Prevents transmission to an exposed opponent
  • Antivirals
    • Primary Infection
      • Valacyclovir: 1000 mg twice daily (or 20 mg/kg 3 times daily for children <20 kg) for 7-10 days
    • Recurrent infection
      • Valacyclovir: 500 - 1000 mg twice daily for 7 days
    • Prophylaxis
      • Valacyclovir 500 mg PO daily (if most recent infection >2 years ago)
      • Valacyclovir 1 g PO daily (if most recent infection <2 years ago)
  • Prophylaxis
    • Athletes with a history of herpes labialis, herpes genitalia, herpes gladitorum should consider season-long prophylaxis
  • Suspend athletic participation
    • Athletes must cease all sporting activity when diagnosed and during treatment
    • Return to play is decisions should follow established national guidelines
  • Antibiotics
    • Not indicated unless super imposed infection is suspected
    • Note that patients are often treated with antibiotics for a presumed case of folliculitis


  • Hygiene
    • Athletes should shower immediately after practice
    • Use their own soap, towels, and razors.
    • Towels washed after each use with hot water, detergent
  • Skin Hygiene
    • Wash hands often
    • Do not pick, squeeze skin lesions
    • Report any suspicious lesions to coach or athletic trainer
  • Equipment
    • Practice and competition gear cleaned after each use with soap and water
    • Disinfect training mats after use
  • Valacyclovir prophylaxis
    • Shown to decrease risk of HSV acquisition, prevent recurrence of previous, outbreak
    • True in both HSV-seropositive and HSV naïve wrestlers
    • At a wrestling camp, daily oral valacyclovir decreased recurrent outbreaks by 89.5%, prevented contraction of the virus[3]
    • Recommend starting at least 5 days before the season, camp or tournament

Rehab and Return to Play


  • Not applicable

Return to Play/ Work

Primary Herpes Zoster Infection

  • NCAA Guidelines[12]
    •  Must have firm, adherent crust at time of participation
    •  No evidence of secondary bacterial infection
    •  No new blisters for 72+ hours
    •  120+ hours of antiviral therapy
    •  No systemic symptoms
    •  May not cover active infections to allow participation
  • NFHS[13]
    •  All lesions scabbed over
    •  No new lesions for 48+ hours
    •  10+ days of antiviral therapy for cutaneous lesions only
    •  14+ days of antiviral therapy if systemic symptoms

Secondary Herpes Zoster Infection

  • NCAA Guidelines
    •  Must have firm, adherent crust at time of participation
    •  No evidence of secondary bacterial infection
    •  No new blisters for 72+ hours
    •  120+ hours of antiviral therapy
    •  May not cover active infections to allow participation
  • NFHS
    •  All lesions scabbed over
    •  No new lesions for 48+ hours
    •  120+ hours of antiviral therapy

Complications and Prognosis


  • With proper treatment, most athletes have an excellent prognosis


  • Herpes keratitis (ocular herpes)
    • Conjunctival scarring
    • Vision loss
  • Recurrence

See Also


  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.
  2. 2.0 2.1 Anderson, Bruce J. "The epidemiology and clinical analysis of several outbreaks of herpes gladiatorum." Medicine and science in sports and exercise 35.11 (2003): 1809-1814.
  3. 3.0 3.1 3.2 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.
  4. 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 through 2003-2004. J Athl Train. 2007;42:303-310.
  5. Centers for Disease Control and Prevention. Genital herpes—CDC fact sheet. 2017. http://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm. Accessed September 12, 2017.
  6. 6.0 6.1 Peterson, Andrew R., Emma Nash, and B. J. Anderson. "Infectious disease in contact sports." Sports Health 11.1 (2019): 47-58.
  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.
  8. Anderson, B. J. "Managing herpes gladiatorum outbreaks in competitive wrestling: the 2007 Minnesota experience." Current sports medicine reports 7.6 (2008): 323-327.
  9. Selling, Ben, and Sidney Kibrick. "An outbreak of herpes simplex among wrestlers (herpes gladiatorum)." New England Journal of Medicine 270.19 (1964): 979-982.
  10. Wei, Elizabeth Y., and Daniel T. Coghlin. "Beyond folliculitis: recognizing herpes gladiatorum in adolescent athletes." The Journal of Pediatrics 190 (2017): 283.
  11. Johnson, Rob. "Herpes gladiatorum and other skin diseases." Clinics in sports medicine 23.3 (2004): 473-484.
  12. National Collegiate Athletic Association. Sport Science Institute. 2017. http://www.ncaa.org/sport-science-institute. Accessed October 10, 2017.
  13. National Federation of High School Associations. Sports Medicine Advisory Committee. https://www.nfhs.org/sports-resource-content/nfhs-sports-medicine-position-statements-and-guidelines/. Accessed October 10, 2017.
Created by:
John Kiel on 23 June 2019 01:15:20
Last edited:
19 March 2022 12:21:09