Pregnancy and breastfeeding

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Expectant and new mothers often seek treatment for skin conditions experienced during pregnancy and breastfeeding. In addition, these women also may be caring for skin conditions unrelated to their pregnancy.

Dermatologist Jenny E. Murase, MD, FAAD, assistant clinical professor of dermatology at the University of California, San Francisco, summarized skin conditions pregnant and breastfeeding women may experience as well as some treatments that are safe for mom and baby.

Consult a dermatologist about treatment of skin conditions during pregnancy

If a medication is not medically necessary, it should be avoided during pregnancy and, in general, cosmetic therapies should be avoided even if their risk to the fetus is likely low. Each patient should consult with her dermatologist before starting or stopping any treatments. The following are Dr. Murase's recommendations for some common skin conditions in pregnancy:

Acne

  • Topical prescription therapies are generally considered safe during pregnancy.

Atopic dermatitis

  • Topical steroids can be safely used in pregnancy.
  • Before using oral cortisones, particularly during the first trimester of pregnancy, the risks and benefits should be considered due to a risk of oral clefts in the babies of patients who used oral cortisones during pregnancy.
  • Women in their third trimester of pregnancy should consult their physician before using antihistamines since, at high doses, they can cause contractions of the uterus as well as withdrawal symptoms in infants.

Psoriasis

  • Ultraviolet B (UVB) phototherapy is generally considered the safest form of psoriasis therapy during pregnancy.
  • Since UV light breaks down the body's store of folic acid and deficiencies of folic acid can result in oral clefts and other birth defects in babies, it's important that women of childbearing age, especially those being treated with UV light for psoriasis, take folic acid daily if there is a chance that they may become pregnant.
  • Pregnant women should consult with their dermatologist before taking biologics since these drugs are relatively new and there is little data to support their safety in pregnancy.

Skin infections: Bacterial

  • Penicillin, cephalosporins and rifampin are the safest antibiotics for use during pregnancy.
  • Erythromycin should be prescribed as a secondary treatment option in the first trimester.

Skin infections: Fungal

  • Topical anti-fungals are generally considered safe, and nystatin is considered the safest.

Skin infections: Viral

  • Acyclovir is in general considered safe in pregnancy, but it should not be taken throughout the pregnancy to prevent breakouts of genital herpes. However, if a woman is planning a vaginal birth and has a history of genital herpes, she should take the medicine every day starting when she is 36 weeks pregnant.

Warts

  • Over-the-counter preparations that have salicylic acid are considered safe.
  • For cases that require a doctor's treatment, liquid nitrogen is the treatment of choice during pregnancy.

Treatment of skin conditions during breastfeeding


The vast majority of medications prescribed by dermatologists are safe to use during breastfeeding and should have no effect on milk supply or infant well-being. Each patient should consult with her dermatologist before starting or stopping any treatments. The following are Dr. Murase's recommendations for some common skin conditions:

Acne

  • All topical and most oral antibiotics are considered safe during lactation, but the tetracycline class of antibiotics should only be used for three weeks or less.

Atopic dermatitis

  • Most topical steroids are considered safe and can be used directly on the nipple.
  • Patients with a flare postpartum do not have to refrain from breastfeeding or pump and discard their breastmilk when they are on a prednisone taper. However, the mother should wait approximately four hours after taking prednisone to breastfeed.

Skin infections

  • Most oral and topical medications for bacteria, fungi and viruses are considered safe when breastfeeding.

Psoriasis

  • Nursing mothers should use UVB light treatment instead of PUVA (psoralen + UVA).

Warts

  • Treatments with salicylic acid and liquid nitrogen are considered safe for breastfeeding mothers.

Common skin conditions experienced during breastfeeding


Nursing can be a painful struggle for both mother and child. One study of 100 women found that 96 percent experienced sore nipples in the first week of breastfeeding, which peaked at days 3 to 6.1

Nipple dermatitis

  • The most common reason why it initially occurs is because of poor latch, which is the position of the baby's mouth on the mother's nipple.
  • Lactation consultants can make recommendations to the mother to improve latch and limit the abrasions and trauma to the nipple.

Breast pain


Breast pain also may be caused by an underlying dermatologic problem such as atopic dermatitis or allergic contact dermatitis, plugged ducts, fungal and bacterial infections, and Raynaud's phenomenon, which occurs when blood vessels constrict due to a drop in temperature of the skin and cause pain.

Atopic dermatitis/allergic contact dermatitis

  • Nursing mothers with a history of atopic dermatitis are more likely to experience nipple dermatitis.
  • Dermatitis may be caused by an allergy to lactation bras and lanolin, which is recommended by lactation consultants to soothe tender nipples.
  • If hydrogels are used, reduce infection risk by cleaning them after each use with soap and water and replacing them at least every three days.
  • Warm water compresses have been shown to effectively reduce pain. Certain home remedies should be avoided as these may actually harm the nipples.

Plugged ducts

  • If superficial, these appear as small blisters on the nipples and result in a sharp, stabbing pain. If they occur deeper in the breast tissue, a tender, non-inflammatory lump in the breast may be found.
  • Plugged ducts may be caused by tight-fitting bras or infrequent expression of milk.
  • Milk blisters, which are superficial plugged ducts, can be treated with fine needle aspiration.
  • If milk blisters are recurrent, pumping mothers should use the lowest settings possible on the suction and verify the breast shield size with a lactation consultant.
  • It is critical to see a dermatologist in order to distinguish milk blisters from herpes simplex virus, which could cause an infant to develop a life-threatening infection.
  • A chronically plugged duct may result in creating a milk cyst or galactoceles. Larger cysts need to be surgically removed to prevent infection.

Fungal and bacterial infections

  • When milk stagnates and is not regularly expressed, inflammation of breast tissue (mastitis) can result.
  • Mastitis may be characterized by physical discomfort and a high fever (above 100 degrees).
  • Patients who believe they may have mastitis should seek medical care as an antibiotic or antifungal treatment may be needed.

Raynaud's phenomenon

  • Pain and temporary loss of color can occur when small arteries of the nipple constrict or vasospasm due to a drop in temperature.
  • This condition is thought to be quite rare when involving the nipple, but quite common when involving the hands, affecting up to 20 percent of women.2
  • If mothers believe they may have Raynaud's phenomenon, they should consult their physician for treatment options and avoid external agents that constrict blood vessels such as cold temperatures and caffeine.

1Tait P. Nipple pain in breastfeeding women: causes, treatment, and prevention stratgies. Midwifery Womens Health 2000; 45: 212-5.
2Emedicine. Raynaud Phenomenon

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