When my daughter first told me she was pregnant, we talked about her psoriasis and her concerns with whether she would successfully breastfeed. She was diagnosed with guttate psoriasis following a round of antibiotics for a strep infection in her leg. Although I hadn’t shared this with her, I too was concerned about whether her breastfeeding experience would be enjoyable, or riddled with cracked nipples and ongoing pain.
Psoriasis and breastfeeding isn’t well reported in the literature and how to treat it is a bit of a guessing game. Dr. Newman’s famous nipple cream is often the go-to, but as a long term therapy, this is far from ideal. My attention was then directed towards learning more about those who suffer various skin conditions and how they have made it work during their breastfeeding experiences.
Eczema of the Nipple and Areola
The incidence of eczema of the nipple and areola is unknown, as literature to date is largely limited to case reports. These cases are particularly challenging to identify and manage, as they don’t tend to follow the same rules as those in the non-lactating population. Generally, eczema presents on the areola and spares the nipple. It may present rather abruptly as vesicles, crusting, and erosions although consultants are inclined to assume this is a herpes outbreak and ask clients to pump until healed as herpes can be detrimental to the neonate. It can also present in a more dry, reddened, thick and leathery, even scaling manner that advances slowly and becomes chronic. Mothers generally describe this as itchy, painful, or that it burns.
The skin of the nipple and areola are similar to that of the trunk, head, and limbs which can also be victim to eczema. These lesions may be related to an irritant that has come in contact with the areola or it may be an allergic response. Less often, eczema may be related to nutritional deficiencies or be hormone-induced. Mothers with endogenous atopic eczema are more prone to nipple eczema. This is a more chronic presentation related to a deeper pathologic cause. Experts Barankin and Gross (2004) share that in their clinic, “approximately half of breastfeeding women who developed nipple and areola eczema had a prior history of eczema and the other half developed it as a contact dermatitis following introduction of solids to the infant’s diet” (p 126).
Irritant Contact Dermatitis
Irritation can cause dermatitis and this has been reported by mothers from agents as simple as water, soaps, detergents, and fragrances. Washing the nipples with soap or applying ointments containing irritants may be enough to cause skin irritation. Clothing washed in bleach has also been the culprit.
Allergic Contact Dermatitis
Allergic contact dermatitis is tricky because the response can be delayed. A hypersensitivity to any allergen though can cause eczema. Offending agents can include chamomile, vitamins A and E, aloe vera, and perfumes. Lanolin is often provided to women in the hospital, sometimes as routine to breastfeeding women and fresh ice to a surgery patient. However, this waxy substance is obtained from the wool of sheep, who are sprayed with all sorts of chemicals to reduce infestation, and while the product is meant to be therapeutic, it may in fact be the offender. Preservatives have also been reported to cause dermatitis from some mycostatin formulations (for treating yeast).
Bacterial Infections of the Breast
Impetigo and cellulitis can cause skin eruptions on the breast, although these are typically limited to one breast. Treatment with antibiotics is certainly required. Abscesses can occur and in this scenario, your midwife or practitioner will need to create an incision and drain the wound.
One of the toughest to treat, yeast in the breastfeeding couple is often itchy and described as burning or stinging. Shininess is often ominous, with some erythemia although this is not always present and thickening or hardening of the skin may also be observed. Typically this presents only where the baby’s mouth comes in contact with the breast. A trick for differentiating yeast of the breast and eczema is that while eczema will spare the skin at the base of the nipple, yeast will not and often the clinician will observe fine, hair-line cracks at the base. Symptoms can present rather sudden, after antibiotic use for example, and many times mom will also have vaginal yeast or baby will have thrush or a diaper rash. All need treated.
This is the zebra that all lactation consultants are trained to consider. Paget’s disease is a carcinoma that infiltrates the nipple and while most are in post-menopausal women, there have been cases of breastfeeding women with skin irritations that went undiagnosed because it was assumed to be exclusively breastfeeding related. Paget’s disease is typically limited to one side, and again, is a chronic eczematous-appearing rash of the areola and nipple. It would of course, not respond to medical therapy so clinician’s should be suspicious of Paget’s if any unilateral “eczema” persists for more than 3 weeks. Treatment would be surgery, radiotherapy and/or chemotherapy. This would be exceptionally rare in the breastfeeding woman.
Certainly the hope of midwives and lactation consultants is to prevent any incidence of eczema through obtaining a thorough history, identifying atopy, eczema, allergic and irritant contact dermatitis and eliminating such agents from the environment. Interestingly, nipple eczema can occur for the first time when solid foods are introduced into the infant’s diet. In this case, the mother can be instructed to wipe the baby’s mouth out with water or eliminate such foods from the diet, although certainly it may be that solid foods were introduced prematurely and encouragement in maintaining an exclusively breastfed relationship may be the best advice.
Moisturizing can be an important step in those who suffer with eczema. Our boutique offers a natural nipple butter that is lanolin-free, with zero toxins and is certified organic. This cream is made with soothing organic calendula and non-sticky natural plant butters to comfort and protect the nipple and areola. It is safe for baby too – no need to wash it off before nursing.
Topical corticosteroids are the more popular treatment of medical providers and are sometimes necessary for lactating women suffering from eczema. Certainly if you feel you are suffering from eczema and you are a client of Believe Midwifery, speak to our midwife and lactation consultant and if appropriate, we can provide a prescription for you. However, the use of corticosteriods should be closely supervised and of course, minimized.
Your midwife may prefer to culture your breast prior to prescribing, and this would be wise, as Staphylococcus aureus is a common skin pathogen that causes skin fissures and loss of skin integrity. If steroids were initiated prior to identification, such infection could quickly grow worse.
Finding Good Support
Breastfeeding is ideal for mothers and babies. Unfortunately, most practitioners are not sufficiently trained in how to support it under ideal circumstances, let alone help manage them under challenging ones. If your clinician is unfamiliar or not giving you the answers you need, contact your local IBCLC for direction. Rarely do circumstances present that genuinely require weaning, although lack of support certainly can make success seem impossible.