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Lactation and medications used in dermatology

Author: Dr Caroline Mahon, Dermatology Registrar, Christchurch, New Zealand, 2011. Acknowledgements: The article was reviewed and improved by the following people: Cara Hafner, RN, IBCLC Lactation Consultant Christchurch Women's Hospital, and Marcia Annandale, IBCLC. Independent Lactation Consultant, Christchurch, New Zealand. Updated by Dr Catherin Nelson-Piercy. April 2018. DermNet NZ Update July 2021


Lactation and medications used in dermatology — codes and concepts
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Breastfeeding for mothers with skin problems

There are many proven benefits for infants and mothers who breastfeed. Breastfeeding should be encouraged and supported wherever possible. Women with longstanding or severe skin conditions should be counselled during their pregnancy about the care of their skin disease postpartum and specifically during lactation. Seeking advice from a lactation consultant is recommended.

Medications during breastfeeding

Some medications used in the treatment of skin conditions are unsuitable during lactation. Alternatives should be considered if first choice dermatologic medications are contraindicated. However, there may be circumstances in which this is not possible due to the severity of the maternal skin disease and decisions with regard to breastfeeding should be made on a case by case basis.

Commonly prescribed medications in dermatology

Antibiotics

  • Penicillins and cephalosporins: safe to use when breastfeeding
  • Macrolides: erythromycin, azithromycin, and clarithromycin are compatible with breastfeeding. Although some studies suggested an association with pyloric stenosis in neonates breastfed at <2 weeks of age, this has not been found consistently and short term use of erythromycin in usual dose is regarded as safe.
  • Tetracyclines have been regarded as contraindicated in breastfeeding due to risk of interference with bone growth and dental development in the infant. However short-term use  (<3 weeks) has not been found to have any adverse effects.
  • Sulphonamides/trimethoprim: are regarded as safe for breastfed infants but should be avoided for lactating mothers of premature infants, jaundiced neonates, or those with glucose-6-phosphate deficiency. [see Sulfa drugs and the skin]
  • Fluoroquinolones: such as ciprofloxacin carry an unproven theoretical risk of causing arthropathy in a breastfed infant but appear to be safe.
  • Rifampicin: compatible with breastfeeding.
  • Topical clindamycin and metronidazole: compatible with breastfeeding.

Antibiotic use by a breastfeeding mother may be associated with gastrointestinal symptoms such as diarrhoea, candidiasis, and drug rashes in the infant.

Antivirals

  • Aciclovir, valaciclovir, famciclovir: compatible with breastfeeding. Famciclovir has been found in high levels in milk in animal studies, so aciclovir or valaciclovir are the preferred options.
  • Topical wart treatments: liquid nitrogen and topical salicylic acid are regarded as the preferred treatments when breastfeeding.

Topical antifungals

  • Clotrimazole: compatible with breastfeeding.
  • Nystatin: compatible with breastfeeding.
  • Miconazole: is the preferred topical azole, compatible with breastfeeding.
  • Topical terbinafine: as less than 5% of the applied dose is absorbed through the skin, topical use is regarded as safe when breastfeeding.
  • Topical ketoconazole: compatible with breastfeeding
  • Gentian violet 0.5–1%: routinely used in US, UK and Canada for candidiasis of the nipple. No longer available in New Zealand.

All topical antifungals are likely to be safe to use when breastfeeding. [see Topical antifungal medication]

Oral antifungals

  • Fluconazole: compatible with breastfeeding.
  • Oral ketoconazole: compatible with breastfeeding.
  • Griseofulvin: incompatible with breastfeeding due to risk of effects on neonatal development. No longer available in New Zealand.
  • Oral terbinafine: not recommended when breastfeeding as it is used in long courses and there is insufficient information to support its use.

For further information see Oral antifungal medication.

Antipruritics

  • First-generation antihistamines: Promethazine, chlorpheniramine, and diphenydramine are present in breast milk and can cause drowsiness and irritability in a breastfed infant. Not recommended.
  • Second-generation non-sedating antihistamines: Cetirizine, fexofenadine and loratadine: compatible with breastfeeding when used in low/standard dose.
  • Doxepin: incompatible with breastfeeding.

Immunomodulators

  • Hydroxychloroquine: longterm daily use for connective tissue disease such as lupus erythematosus when breastfeeding is controversial due to slow elimination rate and potential toxic levels accumulating with effects on the eyes, ears and development of the infant. However it is generally felt it is safe to use if the benefits for the mother outweigh potential risks to the infant and the infant is carefully monitored.
  • Ciclosporin: contradictory advice, with the American Academy of Pediatrics recommending to avoid with breastfeeding despite the lack of documented harm.
  • Azathioprine: excretion in breast milk has been shown to be very low in a small sample of lactating women; recommend breastfeeding at least 4 hours after taking dose and monitoring the infant's liver function and white cell count.
  • Methotrexate: contraindicated in breastfeeding 
  • Mycophenolate mofetil: contraindicated in breastfeeding
  • Cyclophosphamide: contraindicated in breastfeeding for up to six weeks after last dose.

Biologics 

Topical anti-psoriatics

  • Calcipotriol: compatible with breastfeeding. No reports of adverse effects on breastfeeding.
  • Topical tar preparation: probably safe in breastfeeding. Do not apply to nipple or areolae and probably best avoided.
  • Topical salicylic acid containing preparations: no data. Caution in breastfeeding. Potentially hazardous in systemic doses. Do not apply to nipple or areolae.
  • Tazarotene: caution if using on large skin areas when breastfeeding.

Systemic anti-psoriatics

  • Acitretin: contraindicated in breastfeeding due to risk of cumulative toxicity.
  • Phototherapy: Ultraviolet B phototherapy is safe to use when lactating, however PUVA (topical, oral) is probably best avoided due to the risk of photosensitisation.
  • Hydroxyurea: contraindicated when breastfeeding
  • see above for: methotrexate, ciclosporin, biologics

Corticosteroids

  • Prednisone: oral prednisone in short courses compatible with breastfeeding, and best to wait four hours to breastfeed after taking the dose. Prolonged or high dose therapy not contraindicated in breastfeeding; however, the infant requires close monitoring for growth and development.
  • Topical corticosteroids: apply topical corticosteroids to breasts and nipples after nursing. Ointments are preferred over creams. The steroid potency, quantity used, and duration of therapy should be minimised.

Topical calcineurin inhibitors

  • Pimecrolimus, tacrolimus: compatible with breastfeeding, however if use is required on the breast it should be applied after nursing and the nipple should be carefully cleaned before nursing. Avoid direct contact between the infant's skin and a treated area.

Oral contraception and other hormonal therapies

  • Oestrogen, combination oral contraceptives: not recommended in breastfeeding mothers – suppression of lactation is a significant concern.
  • Progesterone-only pill: oral contraceptive of choice in breastfeeding women.
  • Anti-androgen therapy: Spironolactone - compatible with breastfeeding. 

Insecticides

  • Permethrin: recommended as the first-line agent. Compatible with breastfeeding.
  • Ivermectin: use with caution however milk levels are low with limited transfer to the infant. American Academy of Pediatrics regards ivermectin as safe to use when breastfeeding.
  • Malathion: incompatible with breastfeeding due to reports of respiratory depression in the infant.
  • Lindane: incompatible with breastfeeding due to reports of seizures and abnormal liver function.

Analgesics

  • Ibuprofen, paracetamol (acetaminophen): compatible with breastfeeding - recommended analgesics and anti-inflammatories in nursing mothers.
  • Opioid analgesics, codeine: commonly used analgesic in the post-partum period. Reports of drowsiness, central nervous system depression and, rarely, neonatal deaths due to opiate transfer through breast milk in women using codeine – caution advised.
  • Aspirin: compatible with breastfeeding when administered in small doses (80 mg/day) with monitoring of the infant for bruising and bleeding. Potentially hazardous in higher doses - risk of Reye syndrome and metabolic acidosis in the infant.

Acne therapies

Others

  • Topical minoxidil: compatible with breastfeeding
  • Lignocaine (lidocaine): used in local anaesthetics is compatible with breastfeeding, even when mixed with low concentrations of adrenaline (epinephrine). [see Local anaesthesia]
  • Botulinum toxin - although excretion in breast milk is unlikely, use when breastfeeding is not recommended.
  • Bleomycin: contraindicated when breastfeeding

 

This is general advice only and correct at the time of publication. Specific advice should be sought before prescribing for the lactating woman.

  

New Zealand approved datasheets are the official source of information for these prescription medicines, including approved uses and risk information. Check the individual New Zealand datasheet on the Medsafe website.

See smartphone apps to check your skin.
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Bibliography

  • Butler DC, Heller MM, Murase JE. Safety of dermatologic medications in pregnancy and lactation: Part II. Lactation. J Am Acad Dermatol. 2014;70(3):417.e1-427. doi:10.1016/j.jaad.2013.09.009 PubMed 
  • Christensen LA, Dahlerup JF, Nielsen MJ, Fallingborg JF, Schmiegelow K. Azathioprine treatment during lactation. Aliment Pharmacol Ther. 2008;28(10):1209-13. doi:10.1111/j.1365-2036.2008.03843.x Journal 
  • Flint J, Panchal S, Hurrell A, et al. BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding-Part I: standard and biologic disease modifying anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford). 2016;55(9):1693-7. doi:10.1093/rheumatology/kev404 PubMed 
  • Koh YP, Tian EA, Oon HH. New changes in pregnancy and lactation labelling: review of dermatologic drugs. Int J Womens Dermatol. 2019;5(4):216-26. doi:10.1016/j.ijwd.2019.05.002 Journal 
  • Ledingham J, Gullick N, Irving K, et al. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology (Oxford). 2017;56(6):865-8. doi:10.1093/rheumatology/kew479 PubMed 
  • Owczarek W, Walecka I, Lesiak A, et al. The use of biological drugs in psoriasis patients prior to pregnancy, during pregnancy and lactation: a review of current clinical guidelines. Postepy Dermatol Alergol. 2020;37(6):821-30. doi:10.5114/ada.2020.102089 PubMed Central 
  • Rademaker M, Agnew K, Andrews M, et al. Psoriasis in those planning a family, pregnant or breast-feeding. The Australasian Psoriasis Collaboration. Australas J Dermatol. 2018;59(2):86-100. doi:10.1111/ajd.12641 PubMed 
  • Sau A, Clarke S, Bass J, Kaiser A, Marinaki A, Nelson-Piercy C. Azathioprine and breastfeeding: is it safe?. BJOG. 2007;114(4):498-501. doi:10.1111/j.1471-0528.2006.01232.x PubMed 

Books

  • Hale T. Medications and Mothers' Milk, 14th Edition (Hale Publishing,Amarillo, Texas).
  • Lawrence, Ruth A. and Lawrence, Robert M. Breastfeeding: A Guide for the Medical Profession. 7th ed. Elsevier, Health Sciences Division, 2010.
  • Wilson-Clay, Barbara and Hoover, Kay. The Breastfeeding Atlas. 4th ed. LactNews Press, 2008.

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