John presented to the camp health center begrudgingly, after his counselor requested he get a blister on his heel looked at by one of the nurses. The nurse at health check happened to be a new grad without much on-the-ground knowledge of superficial skin lesions. She looked at John’s heel and noticed a circular, red lesion without obvious exudate or oozing, and identified the lesion as a blister. She decided a foot soak, bandage, and antibacterial ointment would do the trick. After completing her treatment, John popped his sneaker back onto his foot and returned to camp life. A couple of days went by, and John returned to the health center. This time, the “blister” had spread. The lesion was now much wetter and wider, and a few other “blisters” had appeared on other parts of his foot — and his white socks weren’t looking very white anymore. Again, the soak, dressing, and antibacterial ointment was applied, and again John returned to camp life.

There is an age-old camp saying that goes something like this: “A day in camp life is a month in the real world.” Why is this important in the context of John’s skin? Well, when campers are living away from their parents/guardians in a communal setting — which often involves sweat, heat, dirt, sometimes lakes, and being slightly less clean than one might be at home — small skin abrasions, cuts, scrapes, etc., can quickly balloon into more serious superficial skin infections. That day or two in a camp setting can really be like weeks or more in the noncamp world. Infections spread and spread quickly.

Skin infections/irritations run the gamut from bacterial to fungal and are even sometimes rashes of viral origin. Today, let’s focus on bacterial infections. 

The skin is rife with millions of normal bacteria that live and feed on the outside of our skin. Skin breakdown can mean that these bacteria easily find an entry point into the body and seed an infection. Skin breakdown in the residential camp setting is easy to come by. Campers are often hot and sweaty. They may not be wearing clean clothing at all times. And they may not always take the time for proper bathing hygiene. Lakes are not bathtubs and can sometimes contain bacteria of their own. All of these factors can work together to exacerbate simple skin breakdown and turn into infections.

Five days pass, and John returns to the health center. This time, his blisters are all over the affected foot. They are red, warm to the touch, oozing, and have a yellowish crust forming at the edges and overtop. They look painful, and John’s counselor didn’t even have to push him to come see the nurses this time. He is uncomfortable.

In its earliest iterations, these mild skin infections can be managed with an over-the-counter topical antibacterial ointment (like Bacitracin). But without prompt management and oversight, these simple bacterial infections can progress to impetigo, which requires slightly more aggressive management. Impetigo is a bacterial infection of the skin and is most frequently caused by A Streptococcus and Staphylococcus aureus. Bacitracin is usually not the ideal choice to manage S. aureus, and this is where it is important to promptly move the camper onto the provider list for prescriptive management.

In John’s case of impetigo, initial management with Mupirocin (Bactroban) ointment would be the prudent choice. With application to the affected areas three times a day for five to seven days, simple cases of superficial impetigo will quickly resolve. A combination of chlorhexidine wash prior to topical antibiotic ointment application can often be key to successful and swift resolution. Any open sores should be covered to prevent further spread of infection, using a breathable dressing when possible.

The concern here is with missed or delayed treatment. A simple lesion can progress rapidly to a wide area of infection, and topical antibiotics just won’t cut it then. In some instances, a severe skin infection may warrant hospital admission and IV antibiotic management, which is obviously something camp health-care providers want to avoid. So what’s the best way to avert such skin infection disasters?

Proper training of all health-care staff and counselors is imperative to maintaining healthy skin and healthy campers.

Education for Health Center Staff

Make sure to discuss:

• Low threshold for transferring a camper (or camp staff member) to an outside medical facility if a skin lesion persists for more than a couple of days with over-the-counter topical antibiotic treatment
• Signs of purulent infection — yellowish crust, oozing, draining pus, warm to the touch, and significant redness
• How lesions may initially look like blisters (or may, in fact, be blisters that then get infected)

Education for Counselors on Hygiene

Make sure counselors understand the importance of the following points for themselves and the campers in their charge:

• Daily bathing with soap
• Regular and effective handwashing
• Frequent changes of clothing, especially to put on clean socks and dry clothes
• Regular washing of bedding and towels
• Seeking help for skin irritations, cuts, scrapes, etc.

Other Important Actions to Take to Mitigate Skin Infection 

Because camp is a communal living situation, it is important to remember that infections can and will spread quickly, and take these precautions:

• Take extra caution in camp areas such as boating, where boat benches and life-vests may be an aid to spreading superficial skin bacteria. Clean areas frequently, and with a proper antimicrobial cleanser.
• Use bug spray to prevent bug bites, which can lead to skin breakdown. And monitor any bites on campers with frequent itching.
• Finally, don’t delay if you are questioning. Seek outside assistance from a medical professional if something doesn’t feel right. Remember, keeping campers healthy is always the goal.

Jane Glazer, MSN, MA, CPNP, FNP-BC, has practiced in urgent care, college health, and residential camp health. She is interested in education, evidence-based best practices, and providing care to campers in a safe and fun way.