Lactation and the skin

Breastfeeding for mothers with skin problems

There are multiple 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 management 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 dermatological medications

Antibiotics

• Penicillins, cephalosporins, topical clindamycin, metronidazole: compatible with breastfeeding. May be associated with gastrointestinal symptoms, candidiasis and drug allergy in the infant.
• Tetracyclines, fluoroquinolones: contraindicated in breastfeeding due to risk of interference with bone growth and dental development in the infant.
• Erythromycin: compatible with breastfeeding. Caution in prescribing in women breastfeeding infants <2 weeks of age, as associated with pyloric stenosis.
• Rifampicin: compatible with breastfeeding.

Antivirals

• Aciclovir, valaciclovir, famciclovir: compatible with breastfeeding. 

Antifungals

• Clotrimazole (topical): compatible with breastfeeding.
• Nystatin (topical): compatible with breastfeeding.
• Fluconazole (oral): compatible with breastfeeding.
• Ketoconazole (oral and topical): compatible with breastfeeding.
• Griseofulvin (oral): no data available. Considered 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.
• Miconazole (topical): preferred topical azole. Compatible with breastfeeding.
• Terbinafine (oral and topical): limited data Caution in prescribing during lactation.

Antihistamines

• Promethazine: present in breast milk. May cause drowsiness in a breastfed infant. Not recommended.
• Cetirizine/loratadine: compatible with breastfeeding.

Immunomodulators

• Hydroxychloroquine, ciclosporin: compatible with breastfeeding<
• Azathioprine: excretion in breast milk has been shown to be very low in a small sample of lactating women [1].
• Methotrexate, mycophenolate, cyclophosphamide: contraindicated in breastfeeding

Biologics 

• Adalimumab, etanercept infliximab: considered safe during breastfeeding
• Anakinra, rituximab ustekinumab: there are insufficient data to address the issue of safety for breastfed infants.

Antipsoriatics

• 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.
• Acitretin: contraindicated in breastfeeding. Potential for toxicity in the breastfeeding infant.
• Topical salicylic acid containing preparations: no data. Caution in breastfeeding. Potentially hazardous in systemic doses. Do not apply to nipple or areolae.>

Corticosteroids

• Prednisone: oral prednisone in short courses compatible with breastfeeding. 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 quantity used and duration of therapy should be minimised.

Topical calcineurin inhibitors

• Pimecrolimus, tacrolimus: compatible with breastfeeding.

Oral contraception 

• 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.

Insecticides

• Permethrin: recommended as the first-line agent. Compatible with breastfeeding.
• Malathion: compatible with breastfeeding.
• Lindane: compatible with breastfeeding.
• Ivermectin: use with caution. Milk levels low. Limited transfer to the infant.

Analgesics

• Ibuprofen, acetaminophen/paracetamol: compatible with breastfeeding.
• Opioid analgesics, codeine: commonly used analgesic in the post-partum period. Rare case reports of 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). Potentially hazardous in higher doses.>

Acne therapies

• Topical therapies: benzoyl peroxide topical retinoids (tretinoin, isotretinoin, adapalene): compatible with breastfeeding.
• Oral isotretinoin: contraindicated in breastfeeding.

Skin problems during lactation

Some common skin problems, particularly of the nipple, areola and breast may appear during lactation/breastfeeding. There may be an underlying skin condition such as atopic eczema or psoriasis contributing to this. It may be that there is poor breastfeeding management also contributing. Alongside treatment of the skin disorder, women are also likely to need support and advice with regard to breastfeeding.

Common presenting problems are described below.

Vaginal dryness

Lactation may result in vaginal dryness and subsequent discomfort. This is a common problem in the postpartum period and is thought to be due to the decline in oestrogen levels during lactation (atrophic vulvovaginitis). Tenderness of the vagina and genital area may also be accompanied by itch. Intercourse may be painful (dyspareunia). There may be splitting or fissuring of the posterior fourchette (the entrance to the vagina). The use of water-based vaginal lubricants can reduce discomfort during intercourse but these sometimes sting or irritate. Petroleum-based products may be better tolerated or also cause irritation; they can cause condom breakage so should be avoided if depending on barrier method contraception. Vaginal moisturisers can also relieve vaginal dryness and pain.

Nipple pain

Nipple hypersensitivity is common during the first postpartum week. Usually, this peaks at day 3–6 and then subsides. Unlike nipple hypersensitivity, pain in the first two weeks postpartum is most commonly due to trauma to the nipple secondary to poor breastfeeding technique. This is associated with nipple redness, swelling and cracking. Injury may range from superficial abrasions to tissue breakdown, a ‘compression stripe’ and shallow fissures, to deep erosions through the dermis complicated by infection. A breastfeeding assessment by a midwife or lactation consultant is advised.

Bacterial nipple infections

A nipple suction injury that does not heal with a change in breastfeeding technique may be a sign of infection. Staphylococcus aureus is the most common infectious organism and may enter the milk ducts via injury to the nipple, which can lead to infective mastitis or breast abscess.

Fungal nipple infections

Nipple candidiasis is over-diagnosed. Pain due to Candida albicans infection is often confused with pain due to poor latching or nipple vasospasm (see below). Early skin breakdown of the nipple in the first few weeks of lactation is usually due to sucking trauma or bacterial infection. Breastfeeding technique should be reviewed by an experienced midwife or lactation consultant. Nipple candidiasis usually presents with the later onset of new nipple pain and generally coincides with oral candidiasis in the breastfeeding infant. Mother or infant may be asymptomatic. Regardless, both infant and mother require treatment.

Nipple dermatitis and eczema

Dry, irritated, and itchy nipples are a common problem during lactation. Postpartum women can have increased skin sensitivity to environmental irritants, and those with an atopic history can present with a flare of nipple eczema. Topical corticosteroids are the main treatment. They should be applied sparingly after a breastfeed. Ointments are preferred to creams.

Nipple eczema

Nipple eczema

Nipple eczema

Nipple vasospasm

This is a common occurrence in women who are experiencing difficulty with breastfeeding. Vasospasm in the vessels of the nipple results in colour change in the nipple and stabbing shooting pain. Vasospasm can occur in women experiencing difficulties with breastfeeding. This is often triggered by an initial injury to the nipple but may also be a response to cold or a manifestation of Raynaud phenomenon. This can be managed by using warm, dry compresses and avoiding cold. Some women have found that squeezing the nipple base and massaging forward can restore blood flow and prevent a painful episode. Input from a lactation consultant or experienced midwife is advised.

Infected Montgomery gland

Montgomery glands are a normal part of breast anatomy. These glands enlarge in pregnancy and have ducts that secrete sebaceous material which lubricates and protects the nipples and areolae in pregnancy and lactation. Mothers should be advised that these should not be squeezed. A small amount of breast milk is also secreted via these tubercles. They may become obstructed, inflamed or infected during lactation. Warm compresses and massage are commonly all that is required.

Blebs or white spots on the nipple

Blebs or white spots on the nipple are milk blisters; these usually appear as painful white clear or yellow dots on the nipple. The pain is often focussed at the spot or directly behind it. This occurs due to sticky breast milk forming a plug within the milk duct. The obstruction may progress to mastitis. Warm compresses may be sufficient to dislodge the plug. Occasionally a plugged milk duct may require dis-impaction using a sterile needle. Consultation with a lactation consultant or midwife is recommended as this may be due to an underlying problem such as breast milk oversupply, and an ill-fitting bra.

Mastitis

Mastitis is inflammation of the breast caused by obstruction to milk flow and if poorly managed, may progress to infection and ultimately abscess formation. Staphylococcus aureus is the most common cause of infective mastitis. In early mastitis, there is breast pain and swelling. There may be red streaks visible in the skin of the breast overlying the mastitis. Systemic symptoms suggesting infection include malaise, fever and chills. Breast milk may appear grainy or stringy. Occasionally there is mucus, pus or blood visible in the breast milk.

The risk factors most commonly associated with mastitis are:

• Infant feeding difficulties leading to engorgement and milk stasis
• Plugged/blocked nipple ducts
• Cracked or bleeding nipples in which the normal skin barrier is eroded
• Nipple and breast pain during feeding
• History of any previous mastitis
• Recent changes to infant feeding patterns (eg, the introduction of a pacifier or bottle feeding)

It is important to identify the symptoms of mastitis as early as possible and address the underlying cause(s) with a full breastfeeding assessment by a midwife or lactation consultant. Recognising risk factors is vital. Progression to breast infection may be averted, and antibiotic therapy may not be required if risk factors are identified and addressed early.

• Remove breast milk regularly (with the infant at the breast and a breast pump)
• Apply cold compresses after feeding to reduce inflammation and pain
• Pain relief may include paracetamol, ibuprofen or if necessary, prescription pain killers

The most important measure is to ensure that breastfeeding continues. Frequent breast milk removal with the infant at the breast and via breast pump is essential in preventing milk stasis. Complete emptying of the breast will assist in recovery. Involvement of a lactation consultant or midwife is strongly recommended.

Lesions on the nipple

A variety of harmless skin lesions may arise on the nipple and occasionally interfere with feeding.

• Viral warts
• Hyperkeratosis of the nipple
• Squamous papillomas
• Seborrhoeic keratoses
• Moles

Skin cancer is rare in this site. Mammary Paget affects the nipple but generally affects older women.

Hyperkeratosis of nipple

Nipple naevus

Hyperkeratosis of the nipple