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 jemurase@gmail.com

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.