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.

Commonly prescribed dematologic medications

 

Penicillins, cephalosporins
Topical 
clindamycin, 
metronidazole

Tetracyclines, fluroquinolones Erythromycin  Rifampicin Aciclovir, valaciclovir, famciclovir
Medication class  Antibiotics Antibiotics Antibiotics Antibiotics Antivirals
Comments Compatible with breastfeeding. May be associated with gastrointestinal symptoms, candidiasis and drug allergy in the infant.             Contraindicated in breastfeeding due to risk of interference with bone growth and dental development in the infant.                                    Compatible with breastfeeding
Caution in prescribing in women breastfeeding infants <2 weeks of age – associated with pyloric stenosis.              
Compatible with breastfeeding.      Compatible with breastfeeding.
 

Clotrimazole
(topical)

Nystatin (topical)

Fluconazole 
(oral)

Ketoconazole 
(oral and topical)

Griseofulvin 
(oral)

Medication class  Antifungals Antifungals Antifungals Antifungals Antifungals
Comments Compatible with breastfeeding.           

Compatible
with breastfeeding.                              

Compatible with breastfeeding.
        
Compatible with breastfeeding.     

No data available. Considered compatible

with breastfeeding.

 

Gentian Violet 0.5-1%

Promethazine

Cetirizine/
loratadine

Hydroxychloroquine Azathioprine
Medication class  Antifungals Antihistamines  Antihistamines Immunomodulators Immunomodulators
Comments Routinely used in US, UK and Canada for candidiasis of the nipple. No longer available in New Zealand. Present in breast milk. May cause drowsiness in breast fed infant. Not recommended. Compatible with breastfeeding.

Compatible
with
breastfeeding.

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.
 

Miconazole
(topical)

Terbinafine 
(oral and
topical)

Methotrexate
mycophenolate,
ciclosphosphamide 
ciclosporin 

Adalimumab
anakinra
etanercept
infliximabrituximab
ustekinumab

Calcipotriol
Medication class  Antifungals Antifungals Immunomodulators Biologics Antipsoriatics
Comments

Preferred topical azole.
Compatible with
breastfeeding.

Limited data.
Caution in prescribing
during lactation.

Contraindicated
in
breastfeeding.

There are insufficient
data to address
the issue of safety
for breastfed infants.

Compatible with breastfeeding.
No reports of
adverse effects
in breastfeeding.

 

Topical tar 
preparations

 Acitretin

Topical salicylic
acid containing
preparations

 Prednisone

Topical
corticosteroids

Medication class  Antipsoriatics Antipsoriatics Antipsoriatics Corticosteroids Corticosteroids
Comments

Probably safe in
breastfeeding.
Do not apply to
nipple or areolae.

Contraindicated in
breastfeeding.
Potential for toxicity
in breastfeeding infant.

No data.
Caution in prescribing.
Potentially hazardous in
systemic doses. Do not apply
to nipple or
areolae.

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.

Apply topical
corticosteroids to
breasts /nipples after
nursing. Ointments  preferred
over creams. Quantity      
used and duration
of therapy should be minimized.

 

Pimecrolimus
tacrolimus

Oestrogen, combination
oral contraceptives

Progesterone-only pill

Permethrin Malathion Lindane
Medication class 

Topical 
calcineurin inhibitors

 Oral Contraception Oral Contraception Insecticides Insecticides Insecticides
Comments

Compatible
with
breastfeeding.

Not recommended in
breastfeeding mothers – suppression of lactation
is a major concern.

Oral contraceptive of
choice in breastfeeding women.

Recommended first line agent.
Compatible
with breastfeeding.

Compatible
with breastfeeding.

Compatible with breastfeeding
 

Ivermectin

Ibuprofen,
acetaminophen
/paracetamol

Opioid analgesics,
codeine

Aspirin

Topical therapies: 
benzoyl peroxide
topical retinoids (tretinoin, adapalene)

Oral isotretinoin
Medication class 

Insecticides

Analgesics Analgesics Analgesics Acne therapies Acne therapies
Comments

Use with caution.
Milk levels low.
Limited transfer to infant.

Compatible
with
breastfeeding.

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. Compatible with breast feeding when administered in small doses (80mg/day). Potentially hazardous in higher doses.

Compatible
with
breastfeeding.

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 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 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:

  • 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 previous mastitis
  • Recent changes to infant feeding patterns (e.g., 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/or 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/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.

Nipple lesions

 

Related Information

References:

  • Azathioprine and breastfeeding: is it safe? Sau A, Clarke S, Bass J, Kaiser A, Marinaki A, Nelson-Piercy C. BJOG. 2007;114(4):498.
  • Medications and Mothers' Milk, 14th Edition (Hale Publishing,Amarillo, Texas) by Thomas Hale.
  • 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.
  • Medicine Use in Lactation – Medsafe New Zealand Prescriber Update 36(2): 22-25, June 2015 June 2015

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Note: The New Zealand approved datasheet is the official source of information for this prescription medicine, including approved uses and risk information. Check the New Zealand datasheet on the Medsafe website.