How to treat rashes of the nipple and areola

Moisture Associated Skin Damage, contact dermatitis, and allergic dermatitis

In my clinical experience, the most common cause of rashes on the nipple and areola are the various lotions, creams and ointments that women apply, in an attempt to help with nipple pain and damage.

These applications include pharmaceuticals like anti-fungal treatments or mucpirin antibiotic cream, hydrogel discs, lanisinoh, polymem (or Nursicare), vitamin A and E, Vaseline or other emollients, and Jack Newman’s All Purpose Nipple Ointment (which is a concerning mix of steroid, antibacterial and antifungal creams).

This kind of rash is red and has a clearly defined edges on the areola, corresponding with where contact has been made with the trigger, such as a hydrogel disc.

Some attempt a distinction between an irritant contact dermatitis and an allergic contact dermatitis.25 It is said that the contact with certain agents causes chemical damage to the skin (like soaps and clothing bleaches), resulting in contact dermatitis. An allergic contact dermatitis is a delayed hypersensitivity reaction to an allergen in a topic agent applied to the nipples, a reaction to the various chemicals contained in the whole range of applications, even lansinoh.

However, I don’t think that this is a helpful distinction. Now, I think of it as Moisture Associated Skin Damage, which occurs in 50% of people when a moist substance is held against the skin, resulting in overhydration of the epidermis.

If the rash is mild, you might use breastmilk and as much air exposure as possible. To avoid sticking in the breast pad, you would use a steroid ointment. If the rash is moderate or severe and needing to be treated, a steroid such as metamethasone (or in America triamcinolone) is advised, perhaps twice in the first day, then daily afterwards for 5-7 days or until resolved.

Eczema or atopic dermatitis

If you have a history of eczema or allergic dermatitis elsewhere on your skin, you are more likely to develop an eczematous rash of the nipple and areola. It may be acute, that is, fresh and sore, with blisters and erosions, weeping and with crust formation, and very painful. Sometimes the weeping or pus from these sores is a Staph Aureus overgrowth and copious enough to make us wonder if there is a secondary infection.

Or it may be dry and scaling, with lichenified or thickened areas, and feel itchy or burning. If it is mild and not painful, you may take no further action. If it is troubling you, it will require a steroid cream or ointment. The ointment may prevent an angry rash from sticking to the breastpad. You would apply a steroid application like mometasone twice in the first day, then daily until resolved.

It’s important to avoid any rubbing or scratching of a dermatitis, no matter how itchy it is! Think of the itchiness as the rash healing up and use a steroid cream.

If the dermatitis is severe and not resolving with other treatments, your doctors may prescribe you a course of oral steroid (prednisolone) for even up to three weeks. You would need to wait four hours after a dose to breastfeed, which may cause distress to your baby and yourself.

Psoriasis

If you already have a history of psoriasis, it can sometimes flare on the nipple and areola complex in response to your baby’s suckling. ‘Koebnerization’ may occur: the development of new plaques of psoriasis in areas of injury. This will require attention from your family doctor or dermatologist.

Hyperkeratosis

A woman presented to me once when her little one was two years old, and no longer breastfed. She was thinking ahead to her next pregnancy. She’d had a dreadful experience the first time, as she’d developed brown plaques all over her nipple and areola, dozens of thickened raised brown ‘warty’ like lesions in a carpet. This is a condition known as hyperkeratosis. This is caused by an exuberant overgrowth of the stratum corneum, for reasons that are unknown.

She’d been ashamed and hadn’t really mentioned these until the time came for her to breastfeed – when she immediately suffered extensive cracking between the plaques, and intense pain.

The dermatologist advised that she be treated in advance next time with removal of the hyperkeratosis and use of steroids on the tender exposed tissue underneath.

Pump damage

Pumping can result in an inflamed and even slightly swollen ring with a clear border on the areola. This is a sign that too much areola is being drawn up into the flange.

You can find out how to protect your nipples and breasts during pumping here.

Paget’s disease of the nipple

This is very unusual, cancerous condition. At first, it may seem as though a woman has nipple eczema that slowly advances across her nipple and areolar complex, persisting longer than three weeks. Sometimes the Paget's disease rash is associated with an underlying mass. Please see your doctor, who will organise a skin biopsy.

Selected references

Barrett ME, Heller MM, Stone HF, Murase JE. Dermatoses of the breast in lactation. Dermatologic Therapy. 2013;26:331-336.