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