Caught out by the Skin

Screening and Prevention

Whether annual skin cancer screening provides a survival benefit remains unclear. Unlike cervical or colorectal cancer screening, skin checks lack definitive evidence of reducing mortality. Current best practice emphasizes self-examination (approximately every three months), photoprotection, total body photography (if total mole count is deemed high, e.g., >200), and prompt medical review of suspicious lesions (see figure 1). Nevertheless, targeted surveillance may be justified in high-risk groups such as fair-skinned players, those with significant cumulative UV exposure, a family history of melanoma, numerous atypical naevi, or precancerous lesions. Management of affected players can thus be streamlined and coordinated in conjunction with sports and exercise physicians. 

“A proactive education and tailored surveillance for high-risk individuals are prudent.”

An Overview of the More Common Skin Issues

Over the past two years, Australian clinicians have been conducting annual skin checks for players from junior development squad level through to the national Australian team. Reviewing these visits (approximately 50 screening skin checks per state per year), the top three conditions, aside from photodamage and skin cancer seen in elite cricket players are:

1. The Black Toe (or discolored) (see figure 2)
2. Athlete’s Foot (or tinea pedis) (see figure 4)
3. Acne (see figure 5)

The Black Toe and Heel
The black toe – otherwise known as “subungual hematoma”, is a dramatic black discoloration of the nail (i.e., a bruise trapped beneath the nail plate). Players are often astute to the diagnosis and etiology. The most important reason clinicians need to be confident in making this diagnosis is to distinguish it from a high-risk subungual melanoma. Fast bowlers are particularly vulnerable due to repetitive foot strike and mechanical stress. The nails, particularly the hallux (big toe) and second toe, are at high risk in pace bowlers.

Dermoscopic differentiation relies on pattern recognition: hemorrhages show homogeneous red–purple pigmentation with globules and clearance, while melanoma demonstrates irregular pigmented bands of variable color and width, and micro-Hutchinson’s sign. Larger hemorrhages (>25% of the nail) warrant consideration of a distal phalangeal fracture. Repetitive stress may also result in various nail distortions (see table 1). Preventive measures include wider toe-box shoes and adequate arch support.

Similarly, friction, pressure, and repetitive trauma give rise to discoloration on weight-bearing areas of the feet due to subcornal hemorrhage, otherwise known as ‘talon noir’. These lesions may also mimic melanoma, but dermoscopy reveals distinct red–black blotches with splatter globules that clear with superficial paring.

Chronic mechanical stress contributes to callosities, which clinicians may manage with keratolytics or refer for podiatric care, but players typically are not bothered by this. Warts can look similar, but it is important not to initiate active wart treatment during a player’s season due to the destructive nature of most treatments. The gentlest solution is regular, prolonged, rubber-based duct tape, applied with good occlusion for several days and paring/filing in between⁽²⁾.

Table 1: Nail conditions following subungual hematoma

Athlete’s Foot
Athlete’s foot is a fungal skin infection occurring between the toes, where moisture is trapped and fungus likes to thrive (aka tinea pedis). A diagnostic test is to take a skin scraping with a number #11 blade. The first line of management includes a topical 1% Terbinafine cream once daily for two to four weeks, due to the fungicidal and fungistatic nature of the medication. Clotrimazole, on the other hand, is inconvenient (two to three times per day) and is only fungistatic. Other infections are common and due to close physical contact, sweating, and occlusive gear. These include bacterial impetigo and viral herpes simplex. Using an antiseptic body wash intermittently (Triclosan or Chlorhexidine 2%) helps minimize bacterial skin infections (impetigo/folliculitis). Prolonged sun exposure is a known trigger for herpes labialis (i.e. cold sore, typically due to HSV1, sometimes HSV2) and if frequent or symptomatic, prophylaxis with an antiviral medication can help (valaciclovir 500mg daily or famciclovir 500mg twice daily). 

Furthermore, heat, trauma, and shared change rooms facilitate onychomycosis (nail fungus). Diagnosis relies on obtaining nail clippings for microscopy, culture, or PCR, with treatment tailored to severity, ranging from topical antifungal lacquers to systemic agents (terbinafine, itraconazole, fluconazole). Preventive hygiene measures are critical. Cutaneous fungal infections present as pruritic, annular plaques with peripheral scaling and central clearing. Topical imidazole’s or terbinafine suffice for localized disease, while systemic therapy is reserved for refractory or widespread cases.

Other sweat-related dermatoses manifesting in cricketers include folliculitis (small red bumps arising from the hair follicle), pityriasis versicolor (a scaly annular asymptomatic rash due to Malessezia furfur yeast infection), Grover’s disease (a mildly itchy red bumpy rash often on the chest and back), and pitted keratolysis (a distinct condition of the soles of the feet with pits, associated with Corynebacteria).

Acne
A significant number of young cricketers will endure acne. Puberty-related acne is common and affects 80% of teenagers. Early treatment is critical for preventing scars, which can occur on the face, neck, chest, or back. A further 40-50% of patients will suffer from acne in their early adulthood (20s or 30s), although it is more common in women. The etiology of acne is multifactorial and includes both genetic and environmental factors. The latter includes temperature or sun exposure, sweating, the application of sunscreens or moisturizers, tight synthetic clothing, and a high-glycemic diet.

Initial treatment includes twice-daily skin cleansing with a salicylic acid cleanser and a topical azelaic acid or benzoyl peroxide 5% wash. Clinicians may prescribe a low-dose medium-duration (three to six months) course of antibiotics (e.g., doxycycline, minocycline, or erythromycin) in combination with a topical retinoid for more persistent inflammatory papules. Athletes may need isotretinoin when acne is persistent or failing conventional combination therapies. Whenever clinicians observe nodules or cysts, they may prescribe oral isotretinoin. Equally, this should be commenced if there is any evidence of scarring or psychological distress from milder acne. Alternative physical therapies such as laser and light are currently in use, but efficacy is variable, and durability is inferior to that of the aforementioned medical therapies.

Conclusion

Skin conditions in cricketers encompass a broad spectrum of traumatic, infective, inflammatory, and neoplastic diseases. Many mimic serious pathologies, such as melanoma, and require careful dermoscopic evaluation for accurate diagnosis. Clinical awareness, together with preventive strategies such as appropriate footwear, foot hygiene, sweat management, photoprotection, and equipment modifications, is essential for maintaining optimal player health.

While cricketers generally enjoy a longer lifespan than the wider population, skin cancer remains a critical occupational hazard, particularly in sun-intense environments like Australia. A proactive education and tailored surveillance for high-risk individuals are prudent. The best UV protection is physical clothing (including hats), and the best sunscreen is the product our players want to apply and, most importantly, reapply.

“The best UV protection is physical clothing (including hats)…”

References

1. Orchard J, Yip L, Chamberlain A, Ming A, Ly L, Swarbrick A, Strathie-Page S, Rubel D. Skin cancer risk in elite athletes – is there more we could do? (A skin cancer audit by Cricket Australia). Poster. Aust J Dermatology 2025. (Poster presentation at ACD ASM 2025 Brisbane). College of Dermatologists Annual Scientific Meeting Brisbane May 2025. 
2. Arch Pediatr Adolesc Med. 2002 Oct;156(10):971-4.