Breast eczema

Skin conditions such as eczema or dermatitis may occur on the nipple and the areola (the flat dark colored part around the nipple). These problems are more common in women who tend to be allergic (eg. have known eczema, asthma or hay fever), or who are pregnant or breastfeeding. Irritant contact dermatitis is caused by inflammation of the skin by products such as shampoos, soap, washing detergents or chemicals. Allergic contact dermatitis is a true allergy to a product used on the skin.

With any of these causes, a rash is seen on the nipple or areola which may be dry or weepy. The rash is usually itchy and may be on one or both breasts. There may be an associated burning pain especially if breastfeeding. In breastfeeding women the symptoms often occur around the time of infant teething or the introduction of solids.

What is eczema?

Eczema is also known as atopic dermatitis or atopic eczema, is a chronic, itchy skin condition that is very common in children but may occur at any age. Atopic dermatitis is the most common form of dermatitis that often begins in infancy or early childhood but can also begin in young adults or even later in life. The skin becomes red, swollen and very itchy. The itchiness may interfere with sleep. The inflammation and itchiness wax and wane in severity.

Atopic dermatitis usually occurs in people who have an ‘atopic tendency’. This means they may develop any or all of three closely linked conditions; atopic dermatitis, asthma and hay fever (allergic rhinitis). Often these conditions run within families with a parent, child or sibling also affected. A family history of asthma, eczema or hay fever is particularly useful in diagnosing atopic dermatitis in infants.

In infants, atopic dermatitis often affects the cheeks, scalp, outsides of the arms and legs and the trunk. In children and adults the inflammation involves the creases in the front of the arms and behind the knee, often the wrists, ankles and buttocks.

The skin is often dry.

Atopic dermatitis arises because of a complex interaction of genetic and environmental factors. These include defects in skin barrier function making the skin more susceptible to irritation by soap and other contact irritants, the weather, temperature and non-specific triggers.

What causes eczema?

Both genetic and environmental influences are important. People with eczema often have relatives with eczema or sensitive skin, asthma, hay fever or allergic conjunctivitis. Hereditary factors predispose a person to having dry skin and a skin barrier that is less able to keep out environmental irritants and allergens. It also predisposes a person to producing immune antibodies to bacteria such as staphylococcal aureus and other allergens.

Each individual has his/her own mixture of predisposing factors.

Does eczema persist forever?

Atopic dermatitis affects 15–20% of children but is much less common in adults. It is impossible to predict whether eczema will improve by itself or not in an individual. Sensitive skin persists life-long. A meta-analysis including over 110,000 subjects found that 20% of children with atopic dermatitis still had persistent disease 8 years later. Fewer than 5% had persistent disease 20 years later. Children who developed atopic dermatitis before the age of 2 had a much lower risk of persistent disease than those who developed atopic dermatitis later in childhood or during adolescence.

It is unusual for an infant to be affected with atopic dermatitis before the age of four months but they may suffer from infantile seborrhoeic dermatitis or other rashes prior to this. The onset of atopic dermatitis is usually before two years of age although it can manifest itself in older people for the first time.

Atopic dermatitis is often worst between the ages of two and four but it generally improves after this and may clear altogether by the teens.

Certain occupations such as farming, hairdressing, domestic and industrial cleaning, domestic duties and care-giving expose the skin to various irritants and, sometimes, allergens. This aggravates atopic dermatitis. It is wise to bear this in mind when considering career options — it is usually easier to choose a more suitable occupation from the outset than to change it later.

What does atopic dermatitis look like?

The appearance varies with the age of the affected person. However, itching, scratching (often breaking the skin with scratching) and rubbing are present in all cases of atopic dermatitis. An itch–scratch-itch cycle may develop that leads to thickening, scaling and redness of the skin.

In infants the inflammation may lead to weeping and crusting. 90% of infants under the age of 6 months will have involvement of the face and neck.

From 2 to12 years the eczema is drier. The knee and elbow creases are involved. The skin of the neck, around the mouth and wrists and ankles is often inflamed. The dryness of the skin becomes more obvious.

From 12 years onwards, including adults, the atopic dermatitis may be more chronic, widespread, severe and treatment resistant. It may also develop for the first time as hand dermatitis or may mainly involve the face. Sometimes other causes of severely itching skin may mimic the changes of atopic dermatitis. The treating dermatologist may need to undertake a biopsy or other investigations to determine the factors contributing to the dermatitis.

What is the treatment for atopic dermatitis?

Treatment of atopic dermatitis may be required for many months and possibly years.

It nearly always requires:

• Reduction of exposure to trigger factors (where possible)
• Regular emollients (moisturizers)
• Intermittent topical steroids

In some cases, management may also include one or more of the following:

• Topical calcineurin inhibitors, such as pimecrolimus cream or tacrolimus ointment
• Crisabarole ointment
• Antibiotics
• Antihistamines
• Phototherapy
• Oral corticosteroids

Longstanding and severe eczema may be treated with an immunosuppressive agent.

• Methotrexate
• Ciclosporin
• Azathioprine

New biologics are under investigation. The first to be approved for the treatment of atopic dermatitis is:

• Dupilumab.

Nipple eczema

Nipple eczema is a localized dermatitis involving the nipple and areola and is characterized by erythema and scaling. Eczema of the nipple occurs when an itchy, scaly, irritated rash develops in the areola (the flat dark colored part around the nipple). It can occur on one or both nipples. Nipple eczema can be a local manifestation of atopic dermatitis/eczema when it arises with classic age-related patterns of eczema on other body sites, or it can occur in isolation. Usually it is caused by irritation from certain articles of clothing, soaps, laundry detergents, or lotions. Nipple eczema often gets better once you identify and remove the cause. Choosing hypoallergenic soaps and detergents free of perfumes and dyes often helps. You may need a short course of topical steroids to treat the eczema.

If you have redness or soreness around the nipple that looks like eczema and doesn’t go away with treatment, you and your doctor also should rule out another uncommon type of breast cancer, Paget’s disease of the nipple. Paget’s disease typically presents as redness, soreness, and flaking that affects the nipple and can easily be mistaken for eczema or infection.

Nipple eczema can occur in anyone as a solitary condition; however, it often occurs in patients with current or past eczema elsewhere. Nipple eczema is mostly diagnosed in teenage girls, regardless of any prior history of atopic dermatitis, but it can also affect infants, children, and older men and women. Nipple eczema may occasionally affect non-atopic breastfeeding women ¹.

Figure 1. Nipple eczema

Nipple eczema causes

A genetic predisposition and environmental triggers cause nipple eczema. It occurs in the context of different types of dermatitis, mainly, atopic dermatitis, irritant contact dermatitis, and allergic contact dermatitis.

• Patients with atopic dermatitis have a higher likelihood of developing nipple eczema. An underlying defect in the skin’s barrier function increases sensitisation and leads to a dysregulated immune response to specific antigens ².
• Irritant contact dermatitis results from irritation by various topical agents, soap, washing detergent, clothing, and fragrances.
• Allergic contact dermatitis is due to a delayed hypersensitivity reaction to contact allergens. The allergen may be an ingredient in a topical agent used on the nipple (eg, fragrance, preservative, lanolin [wool alcohol] or vitamin E), a topical therapeutic (eg, an antibiotic cream), a botanical (eg, chamomile, aloe vera, or tea tree oil), or a metal (eg, nickel associated with body piercing) ³.

Nipple eczema signs and symptoms

Nipple eczema most commonly affects the skin of one or both areolae, but the part of the areola at the base of the nipple and the nipple itself are usually spared. Nipple eczema rarely extends into the periareolar skin (around the areola) or to the rest of the breasts.

Acute nipple eczema can present with erythematous papules and plaques, with vesicles, oozing, crusting, or erosions. Chronic nipple eczema has a dry, scaly appearance, with lichenification on an erythematous or hyperpigmented base. Nipple eczema is often itchy and painful, especially in breastfeeding women ⁴.

Nipple eczema complications

Secondary bacterial infection may occur, due to fissures and the compromised skin integrity in nipple eczema. Colonisation with Staphylococcus aureus can be further complicated with mastitis or breast abscess if not treated promptly.

Other complications include the rare side effects associated with the therapeutic agents used for nipple eczema, such as atrophy from the excessive use of potent corticosteroids or folliculitis from an occlusive emollient ².

Nipple eczema diagnosis

The diagnosis of nipple eczema is made clinically. Occasionally, other tests may be required.

• Patch tests may identify causative antigens in allergic contact dermatitis.
• Mycology (microscopy after application of potassium hydroxide and culture of skin scrapings of the affected area) is warranted if there is an active scaly edge to the lesion or maceration and can help rule out tinea or candida infection of the breast.
• Swabs may be taken for culture to identify any secondary bacterial infection, which may delay response to treatment.
• Skin biopsy can be performed to exclude Paget’s disease, especially in a unilateral disorder of the nipple in an older patient ⁵.

Nipple eczema differential diagnosis

Other conditions that should be considered in a patient with nipple eczema include:

• Allergic contact dermatitis ⁶.
• Bacterial infection (eg, cellulitis, impetigo, or mastitis)
• Fungal infection
• Demodicosis ⁵.
• Other inflammatory skin diseases, mainly psoriasis
• Mammary Paget disease ⁴.

A diagnosis of allergic contact dermatitis should be considered if there is a minimal response to conventional treatment methods for nipple eczema, especially in patients with bilateral lesions extending beyond the areola. Mammary Paget disease, a slow-growing cutaneous form of intraductal carcinoma, should be ruled out in an adult with a unilateral and chronic eczematous lesion of the nipple persisting for more than three months that has not improved after using a topical steroid.

Other rarer conditions that may be mistaken for nipple eczema include erosive adenomatosis, psoriasis, Hailey–Hailey disease, and pemphigus. Skin cancers (eg, intraepidermal squamous cell carcinoma, basal cell carcinoma, and malignant melanoma) should be ruled out when there is a reasonable degree of suspicion ⁴.

Nipple eczema treatment

The multifactorial causes of nipple eczema should be addressed. The prevention of recurrence is key, and patients should be encouraged to avoid precipitating irritants and allergens where these are known. Routine skin care should include moisturizers, as these will help restore the skin’s normal barrier function and reduce pain and itch ⁴.

General measures:

• Avoid soaps and shampoos on the nipple area
• Rinse breasts well, especially after swimming in chlorine
• Avoid hot and long showers
• Do not use any moisturizers other than unfragranced sorbolene on the nipples
• Avoid perfumes and fragranced body products on the breasts
• Avoid padded bras if possible, as the foam padding traps particulate washing powders which are highly irritative to skin.
• Handwash bras (remember sports bras!) with a simple non-particulate soap (eg. Simple soap, Cetaphil, hypoallergenic wool-wash); and avoid excessive soap in cup area of the bra. Rinse bras thoroughly and dry indoors (away from pollens etc). Do not tumble-dry.

Eczema or dermatitis may cause weeping and crusting on the nipple. However, if at any stage you see true nipple discharge coming out of a single duct on the nipple, or if the skin changes on your nipple do not get better with the above treatment, please see your doctor for prompt review as this may indicate a different condition.

Topical corticosteroids (especially in ointment formulation) are the mainstay of treatment for most cases of nipple eczema. They work well and are easily absorbed by the thin areolar skin.

• Moderate potency topical steroids are used for a severe or recalcitrant presentation.
• Low potency steroids are suitable for mild eczema or maintenance therapy following treatment with a moderate potency steroid ³.

In breastfeeding women with nipple eczema, topical steroids should be applied after breastfeeding the infant. Before nursing, these should be then wiped off to avoid potential steroid-related adverse effects by expressing breast milk from the breast and using it to wipe off the steroid ointment; the fat contained in the milk may help retain moisture in the nipple and minimise dryness.

Systemic steroids are rarely necessary for eczema confined to the nipple or the skin of the breast.

Topical calcineurin inhibitors (eg, tacrolimus and pimecrolimus) are also useful, but there is little information in the literature about the potential side effects on the breastfed infant.

Secondary bacterial skin infection (S. aureus) should be treated with antibiotics. Systemic antibiotics have shown better eradication of infection compared to topical antibiotics; they are also less likely to induce methicillin-resistant bacteria and are less likely to result in antibiotic allergy ².

Pain or burning discomfort of the nipples can be relieved by taking paracetamol; this is generally safe in a breastfeeding mother ³.

Breastfeeding and eczema treatments

If you are breastfeeding, you may develop eczema of the areola or nipple. Emollients and mild to moderate potency topical steroids are generally used to treat eczema in this area. They should be applied after breastfeeding and topical steroids should be washed off thoroughly before the next feed. You should also ask your doctor if you can breastfeed while on certain medications.

Nipple eczema prognosis

Nipple eczema tends to run a chronic course with varying degrees of relapse and remission. The aim is to prevent exacerbations by identifying and avoiding precipitating factors.

Patients should be educated on basic skin care. Mild nipple eczema can generally be well-controlled with the avoidance of soap, the application of liberal emollients, and the intermittent application of a topical steroid when the eczema is active ⁴.

References

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