SYMPOSIUM S064
The Breast and Lactation
February 19, 2018
Jenny Murase, MD
Palo Alto Foundation Medical Group University of California, San Francisco
I do not have any relevant relationships with industry.
Objectives
Differential diagnosis and treatment of nipple dermatitis during lactation
“Chronic candidal mastitis”
Raynaud phenomenon of the nipple
www.memorialwest.com/images/motherbaby.jpg
Anticipated… Reality…
www.dermatology.svhm.org.au/Logos/MCH/Graphic
Lactation consultants
Assist with positioning head, body, and mouth to provide the best “latch” (problem in 95% of cases)
The Lactation Consultant Directory:
http://www.ilca.org/i4a/pages/index.cfm?pageid=3432
Breast Pain Problem with latch
Underlying dermatologic problem (atopic dermatitis, psoriasis, or allergic contact dermatitis)
Plugged ducts
Fungal infection (Candida)
Bacterial infection (Staph aureus)
Vasospasm (Raynaud phenomenon)
Underlying dermatologic condition
History of atopic dermatitis or psoriasis
Underlying dermatologic condition
http://chttp://www.accessmedicine.com/loadBinary.aspx?name= wolf&filename=wolf_2e-CD-27t.jpgontent.revolutionhealth.com/
contentimages/images-image_popup-ans7_breast_rash.jpg
Contact allergy to bras or lanolin
Tea bags (tannic acid), honey (spores of Clostridium botulinum), banana or papaya peels (high # microorganisms)
www.lactationconnection.com/detail.aspx?ID=81
Blisters Critical to differentiate milk blisters from
herpes simplex viral infection (life threatening, infant requires IV acyclovir)
http://www.mother-2-mother.com/images/milkblister.jpg
Milk blister (plugged lactiferous duct)
http://mybreastpump.com/PumpsGalore.html
Recurrent milk blisters: -use lowest settings -verify breast shield size
Photo compliments of Dr. Honor Fullerton
http://www.vashishtsurgicalservices.co.uk/images/ pics/abscess2.gif
http://www.vashishtsurgicalservices.co.uk/images/pics/abscess2.gif
Galactocele (milk cyst)
Plugged duct
Mastitis (inflammation breast tissue)
Breast abscess (S. aureus)
Mastitis: fever and malaise; culture & rx amoxicillin, cephalosporins, clindamycin, erythromycin, or dicloxacillin 10-14 days; continue breastfeeding!
No improvement 48 hrs, U/S for abscess; repeated aspirations
5-10%
Milk stasis
3-26%
Axillary mammary tail
http://www.imaios.com/en/e-Anatomy/Thorax-Abdomen-Pelvis/Thoracic-wall-Breast-Illustrations
Mastitis (pt afebrile): A result of staph or candida?
Burning, stabbing pain; flaky/shiny skin
Most pts will be given diagnosis of “candidal” mastitis; 93% of MD’s do not cx
http://www.vashishtsurgicalservices.co.uk/images/pics/abscess2.gif
http://www.mycology.adelaide.edu.au/gallery/photos/candida01.gif
http://newborns.stanford.edu/PhotoGallery/EpsteinPearl2.html
Epstein Pearls (on median palatal raphe)
Candida
http://www.uptodate.com/online/content/images/prim_pix/Candidal_diaper_dermatiti_A.jpg
Candida
Recognizing candida in the infant 25% vaginally delivered
infants are infected
Half of infants (1 wk-18 mos) will culture positive, but only 25% exhibit sx
Bacteria vs. Candida Baby’s mouth: visual examination
Bacterial culture of skin: swab any eroded areas, areola, on nipple, between breasts)
Bacterial culture of breast milk
Fungal cx not possible: requires special processing w/ iron to overcome effect of lactoferrin in milk. Morrill JF, Pappagianis D, Heinig MJ, et al. Detecting
Candida albicans in human milk. J Clin Microbiol. 2003; 41: 475-78.
Truly “candidal” mastitis?
Morrill JF, Heinig MJ, Pappagianis D, Dewey KG. Treatment of mammary candidosis among lactating women. JOGNN 2005; 34: 37-45.
100 women/infants at 2 wks pp
23% colonized (23/100) 77% not colonized (77/100)
87% sx (20/23) 13% no (3/23) 16% sx (12/77) 84% no (65/77)
75% infant sx of thrush
(15/20)
25% none (5/20)
Note: sx = pain, skin changes Clinically suggestive of mastitis
Most colonized w/ candida had sx of mastitis. Most not colonized w/ candida did not have sx of mastitis.
Truly “bacterial” mastitis? 50% breast pain had positive staph culture
If cx staph, treat with oral abx 4-6 wks
Works better: 79% imp w/ oral vs. 16% topical
Reduce risk of mastitis: 25% if not tx’d, 5% if tx’d
Study of 69 women with deep breast pain
50% + cx, 50% - cx: both improved at same rate on antibiotics!! (ave. 6 wks abx, 94% resolution)
50% reported relief with antifungals
(Are we treating the inflammation or infection?)
Livingstone V, Stringer LJ. The treatment of infected sore nipples: a randomized comparative study. J Hum Lact. 1999; 15: 241-6.; Amir LH, Garland SM, Dennerstein L, Farish SJ. Candida albicans: is it associated with nipple pain in lactating women? Gynecol Obstet Invest 1996; 41(1): 30-4.; Eglash A, Plane MB, Mundt M. History, physical, and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain. J Hum Lact 2006; 22(4): 429-33.
Which patient will culture positive for staph?
2 months
2 weeks
Raynaud Phenomenon
Reported in up to 20% of women of childbearing age in the hands and feet
Of those presenting to a dermatology lactation referral center with nipple pain, 25% of women were diagnosed with Raynaud phenomenon
http://www.riversideonline.com/source/images/ image_popup/ans7_raynaudsdisease.jpg
www.hakeem-sy.com/main/files/raynauds-disease.jpg
http://www.visualdxhealth.com/images/dx/webAdult/ raynaudsDisease_34289_lg.jpg
WHITE (pallor)
BLUE (cyanosis)
RED (rubor)
BIPHASIC
TRIPHASIC TRIPHASIC
Raynaud Phenomenon
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.
Raynaud Phenomenon Diagnostic criteria
Chronic deep breast pain (> 4 weeks) that responded to therapy for Raynaud phenomenon and had at least 2 of the following: 1. Observed or self-reported color changes of the nipple,
especially with cold exposure (white, blue, or red)
2. Cold sensitivity or color changes of the hands or feet with cold
3. Failed therapy with oral antifungals.
Nifedipine 30 mg SR tab qhs in 2 wk courses, often require a few courses
Side effects: postural hypotension, headaches
Avoid cold, caffeine, and tobacco
History for nipple dermatitis Seen lactation consultant for latch?
History of Atopy? Psoriasis (Koebnerize)?
Any substances applied to breast (lanolin, tea bags)
Temperature sensitivity (Raynaud’s symptoms)?
Increase risk factors for candidal infection: History of gestational diabetes?
On multiple antibiotics recently?
Diaper rash in infant or thrush in mouth?
Increase risk factors for bacterial infection
Quality of Pain Let down pain: mild pain first few mins, then
12-15 mins after nursing; improves over weeks
Candida: moderate pain worst w/ latch, throughout nursing, radiating/hot w/ refill; dramatic relief 1-3 days w/ oral antifungals
Raynaud’s: moderate pain before/during/after nursing, throbbing, possibly color change
FEED
FEED
FEED
REFILL
REFILL
REFILL
Multifactorial etiology: Dermatologists are in an excellent position to
diagnose, manage, and treat!
Concept courtesy of Dr. Honor Fullerton
http://www.lirmm.fr/bib-icons/Stanford/smile.frown.gif
Atopic dermatitis
Candidal infection
Raynaud’s Plugged
duct
Allergic contact
dermatitis
Bacterial infection
Warm water compresses superior in reducing pain (vs. lanolin or applying breast milk)
Ibuprofen 400 mg q4h (max 2400 mg/day)
Hydrogels (glycerin breast pads)
Replace every 1-3 days, clean with soap/water
Pain management
http://images.google.com/images?hl=en&q=
Soothies&um=1&ie=UTF-8&sa=N&tab=wi
Soothies,
Comfort Gel
Management: topical therapy
Eczematous dermatitis
Mid/low potency cortisone bid x 2 wks
Mometasone twice a day for 3 weeks
Management: topical therapy If suspect infection…
Gentian violet 3-7 days [max 0.5%] or 1 ml nystatin susp baby’s mouth each feed
Wash linens and bras in hot water/1 cup vinegar daily
http://i79.photobucket.com/albums/j151/katiebaker_photos/IMG_0021.jpg http://i33.photobucket.com/albums/d66/shattered- rose/hairescapades010sm.jpg
http://zygotedaddy.blogs.com/zygote_daddy/images/purpleface.jpg
Continue breastfeeding as pain allows even if infection is present
Fungal infection: Fluconazole 400 mg x 1 then 100 mg bid for at least 2 wks
Bacterial infection: Cephalexin (or amoxicillin) for 2 wks
Raynaud: Nifedipine 30 mg SR tab qhs for 2 wks
Management: oral therapy
Resources
Comprehensive review article and patient questionnaire. Heller MM, Fullerton-Stone H, Murase JE.
Caring for new mothers: diagnosis, management, and treatment of nipple dermatitis in breastfeeding mothers. Int J Dermatol 2012 Oct: 51(10): 1149-61.
Pregnancy-Associated Hyperkeratosis of the Nipple
Photos courtesy of Dr. George Kroumpouzos Editor of Atlas of Obstetric Dermatology, JAMA Dermatol. 2013 Jun;149(6):722-6.
Physiologic change of pregnancy
May be symptomatic and persist postpartum
Take-home points
Not possible to culture candida of breast milk in commercial lab (“chronic candidal mastitis”)
Consider candida, staph, and Raynaud phenomenon in cases of chronic mastitis.
References
Mastitis Articles Heller MM, Stone HF, Murase JE. Caring for New Mothers:
Diagnosis, Management, and Treatment of Nipple Dermatitis in Breastfeeding Mothers. International Journal of Dermatology, 51: 1149-61, 2012.
Barrett ME, Heller MM, Stone HF, Murase JE. Dermatoses of the breast in lactation. Dermatologic Therapy. 26: 331-6, 2013.
Lactation Consultant Reference Text Medications and Mothers’ Milk. Thomas W. Hale. 12th ed 2006.
ISBN-10: 0-9772268-3-2
Thank you for your kind attention. Any questions? Comments?
Jenny Murase [email protected]
Disclaimer
This presentation material is intended to serve as an initial reference resource and not as a complete reference resource. It does not include information concerning every therapeutic agent, laboratory, or diagnostic test or procedure available. It is intended for physicians and other competent healthcare professionals who will rely on their own discretion and judgment in medical diagnosis and treatment.