The term eczema is defined as an inflammatory skin condition with erythema, inflammation, papules, vesicles, exudates and crusts, lichenification, skin erosion, fissures, excoriations and desquamation, located in the area of the nipple and/or areola. 

This definition covers several types of dermatitis (seborrheic and atopic) and irritation or hypersensitivity at contact. In addition, this lesion often occurs concomitantly with Staphylococcus aureus skin infections. 

Symptoms commonly manifested by women who suffer from it are: itching, burning and pain both when breastfeeding and when not breastfeeding. 

This occurs more frequently in breastfeeding durations that have exceeded seven or eight months of time and it is a pathology that will probably accompany this woman throughout her breastfeeding journey and will reappear in the form of outbreaks. 

Because it is a term that encompasses different pathologies, there is no common cause for all of them. It is necessary to pay attention to possible causes of contact dermatitis (soap, creams, patches, breast pads, nursing pads, etc.).

The differential diagnosis must include two pathological processes that may be similar at the beginning:

• Scalded skin syndrome due to Staphylococcus aureus infection. In this case, it is possible that this process appears before 6 months of age. To confirm the diagnosis, it would be necessary to perform a milk culture and start empirical treatment with corticosteroids until the results are available. In the case of eczema, as described below, the response to corticosteroid treatment is rapid. However, scalded skin does not resolve with cortisone, but with appropriate antibiotic treatment. 
• Paget’s disease. A rare disease associated with breast cancer, it starts with a lesion on the nipple, which then spreads to the areola and at first would be easily confused with eczema. If treatment of eczema offers little response in terms of symptoms, it will be necessary to reconsider the diagnosis. 

As for the treatment of eczema, it includes:

• Eliminating the allergen if it has become known.
• Initiate topical treatment with corticosteroids. It is recommended to establish a pattern of progressive withdrawal of topical cortisone treatment to reduce the possibility of recurrence. 
• Provide abundant hydration to the affected area. It is important to frequently use moisturizing creams with emollient effect on the lesion, both simultaneously with the corticosteroid treatment, as well as in the withdrawal pattern up to the following two weeks. 
• Frequent washing with soap and water or rubbing the lesion with gauze or any other type of product is not recommended, as it may be counterproductive for the evolution of the lesions. 
• Importantly, sometimes, in eczema, there could be over infection of the lesions, and even sores, therefore it is necessary to assess correctly and add topical antibiotherapy treatment if necessary. 

Considerations regarding breastfeeding

Both the lesion causing eczema and the treatment for it are fully compatible with breastfeeding and it is not necessary to wean the affected breast or discard the human milk. 

If the mother feels pain and prefers to wean temporarily (or definitively) from the affected breast, it is possible to carry out deferred lactation (exclusive pumping) and continue to offer breastmilk extracted from the affected breast or to accompany her in the weaning process. 

The recommendation for applying the topical treatment is to apply it on the affected area after feeding, with a gentle massage. It needs to be left a few minutes for the product to be absorbed before offering the breast to the infant again. If it is not possible to wait, it is advisable to offer the other breast until there are no traces of the product on the nipple or areola. 

Nipple eczema is a lesion with a good prognosis if adequate treatment is applied and concomitant infections, if any, are controlled. However, it is necessary to inform the mother that this is a pathology that is likely to reappear again in time. If she is unaware of this possibility of recurrence, it can generate a situation of frustration. In this way, recurrences, if any, can be detected and treated early. 

Bibliography

Barankin B, Gross MS. Nipple and areolar eczema in the breastfeeding woman. J Cutan Med Surg. 2004;8(2):126-130. doi:10.1007/s10227-004-0116-6

Gilmore R, Prasath V, Habibi M. Paget Disease of the Breast in Pregnancy and Lactation. Adv Exp Med Biol. 2020;1252:133-136. doi:10.1007/978-3-030-41596-9_18

Barrett ME, Heller MM, Fullerton Stone H, Murase JE. Dermatoses of the breast in lactation. Dermatol Ther. 2013;26(4):331-336. doi:10.1111/dth.12071