Lactation and the skin

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.

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.

Medication classCommonly prescribed dermatologic medicationsComments
Antibiotics Penicillins, cephalosporins
Topical clindamycin, metronidazole
Compatible with breastfeeding. May be associated with gastrointestinal symptoms, candidiasis and drug allergy in the infant
Tetracyclines, fluroquinolones 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 – associated with pyloric stenosis
Rifampicin Compatible with breastfeeding
Antivirals Aciclovir, valaciclovir, famciclovir Compatible with breastfeeding
Antifungals Miconazole (topical) Preferred topical azole. Compatible with breastfeeding
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 availablae. Considered compatible with breastfeeding
Terbinafine (oral and topical) Limited data. Caution in prescribing during lactation
Gentian Violet 0.5-1% Routinely used in US, UK and Canada for candidiasis of the nipple. No longer available in New Zealand.
Antihistamines Promethazine Present in breast milk. May cause drowsiness in breast fed infant. Not recommended.
Cetirizine/loratadine Compatible with breastfeeding
Immunomodulators Hydroxychloroquine Compatible with breastfeeding
Azathioprine Excretion in breast milk has been shown to be very low in a small sample of lactating women (1.). The potential benefits of breastfeeding must be weighed against the possible risks.
Methotrexate, mycophenolate, ciclosphosphamide ciclosporin Contraindicated in breastfeeding
Biologics Adalimumab, anakinra, etanercept, infliximab, 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 in breastfeeding
Topical tar preparations Probably safe in breastfeeding. Do not apply to nipple or areolae.
Acitretin Contraindicated in breastfeeding. Potential for toxicity in breastfeeding infant
Topical salicylic acid containing preparations No data. Caution in prescribing. 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 infant requires close monitoring for growth and development.
Topical corticosteroids Apply topical corticosteroids to breasts /nipples after nursing. Ointments preferred over creams. Quantity used and duration of therapy should be minimized.
Topical calcineurin inhibitors Pimecrolimus, tacrolimus Compatible with breastfeeding
Oral Contraception Oestrogen, combination oral contraceptives Not recommended in breastfeeding mothers – suppression of lactation is a major concern
Progesterone-only pill Oral contraceptive of choice in breastfeeding women
Insecticides Permethrin Recommended first line agent. Compatible with breastfeeding
Malathion Compatible with breastfeeding
Lindane Compatible with breastfeeding.
Ivermectin Use with caution. Milk levels low. Limited transfer to infant
Analgesics Ibuprofen, acetaminophen/paracetamol Compatible with breastfeeding
Opioid analgesics, codeine Commonly used analgesic in 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 breast feeding when administered in small doses (80mg/day). Potentially hazardous in higher doses.
Acne therapies Topical therapies: benzoyl peroxide, topical retinoids (tretinoin, 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 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

Postpartum women can have increased skin sensitivity to environmental irritants and those with an atopic history can present with an eczema flare. Topical corticosteroids are the main treatment. They should be applied sparingly after a breastfeed. Ointments are preferred to creams.

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 is commonly all that is required.

Bleb 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/or 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:

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.

The most important measure is to ensure that breastfeeding continues. Frequent breast milk removal with the infant at the breast and/or via breast pump is essential in preventing milk stasis. Complete emptying of the breast will assist 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.

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

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