When a patient complains of breast pain, there are several special considerations for diagnosis and treatment.
The breast presents several potential skin conditions for pregnant and lactating patients. New mothers often anticipate the breastfeeding journey to be an incredible opportunity to bond, and while that can be true, it often comes with pain, inflammation, and sometimes infections on the nipple and breast. This topic was part of the session “Behind the Bra: What Dermatologists Should Know about Diseases of the Breast” at the 2023 American Academy of Dermatology Meeting in New Orleans, Louisiana earlier this month.
“Positioning of the baby’s head, body, and mouth make a difference in providing the best latch, which is the problem in nearly 95% of cases,” said Jenny Murase, MD, associate clinical professor of dermatology at the University of California San Francisco and the director of Medical Dermatology Consultative Services and Patch Testing for the Palo Alto Foundation Medical Group.1 She addressed the importance of referring to a lactation consultant during the session and recommended utilizing the International Board Certified Lactation Consultant directory.
Murase went on to explain that breast pain may not only result from problems with latch, but also underlying dermatologic problems, plugged ducts, fungal infection (Candida), bacterial infection (Staph aureus), or Vasospasm (Raynaud phenomenon).
Underlying dermatologic problems can include atopic dermatitis or psoriasis. Contact allergy to bras or lanolin can also be a culprit of breast pain. Murase suggested a few home remedies including tea bags with tannic acid, honey with spores of Clostridium botulinum, and banana or papaya peels with a high number of microorganisms.
Galactoceles (milk cysts) can lead to mastitis. Murase said she conducts a culture and prescribes antibiotics for 2 weeks. The American Academy of Pediatrics cited that most drugs likely prescribed to a nursing mother should have no effect on supply or on an infant’s well-being. All topical antibiotics are deemed safe, while a couple of oral antibiotics should be monitored. Erythromycin should be avoided at the newborn stage. Tetracyclines should only be used short-term.2
When mastitis comes with burning, stabbing pain, or flaky/shiny skin, patients are sometimes diagnosed with “candidal” mastitis—so how can it be recognized? Candida can be recognized by examining the infant. Nearly 25% of vaginally delivered babies are infected. A baby’s mouth can be observed and cultured. A clinician can also conduct a bacterial culture of skin and swab any eroded areas including the areola, nipple, or between breasts. A bacterial culture of a patient’s breast milk can also be done.3
In the book Medications and Mothers’ Milk2, other medications are evaluated for safety in pregnant and lactating patients. All topical antifungals are safe with the top recommendations being nystatin and clotrimazole. Oral antifungals are also okay with a note about itra-/ketoconazole having low absorption, making milk alkaline. Topical steroid use on rapidly expanding skin is a treatment that should be monitored with caution. For antiviral therapy, it is critical to differentiate milk blisters from herpes simplex viral infections that can be life threatening and lead to a required IV acyclovir for the infant.
The Raynaud phenomenon leaves smaller arteries constricted, limiting blood supply to hands and feet. Nearly 20% of women of childbearing age report white, blue, or red hands and feet from the phenomenon. Of those presenting to a dermatology lactation referral center with nipple pain, 25% of women were diagnosed with the Raynaud phenomenon. Diagnostic criteria include chronic deep breast pain for more than 4 weeks, color changes of the nipple (especially with cold exposure), and failed therapy with oral antifungals. A prescription of nifedipine 30 mg in 2 week courses (sometimes multiple courses are needed) is recommended. Patients are advised to avoid cold, caffeine, and tobacco on the drug.4
“Our role in dermatology is to reassure new mothers that the majority of oral and topical medications are safe,” Murase concluded.
1. Stanford Medicine Children’s Health. Difficulty with Latching On or Sucking. Accessed March 28, 2023.https://www.stanfordchildrens.org/en/topic/default?id=ineffective-latch-on-or-sucking-90-P02650.
2. Hale TW. Medications and Mothers' Milk. Amarillo, Texas: Hale Publishing; 2006.
3. Morrill JF, Pappagianis D, Heinig MJ, et al. Detecting Candida albicans in human milk. J Clin Microbiol. 2003; 41: 475-78.
4. Barrett ME, Heller MM, Fullerton-Stone H, Murase JE. Raynaud Phenomenon of the Nipple in Breastfeeding Mothers: An Underdiagnosed Cause of Nipple Pain. JAMA Dermatology 149 (3): 300-306, 2013.