What is the treatment for an under breast rash?

Treatment of Under Breast Rash

For benign under breast rashes (intertrigo), apply topical low-to-moderate potency corticosteroids (such as hydrocortisone 1% cream 3-4 times daily) along with keeping the area clean and dry, while any suspicious skin changes require immediate diagnostic imaging and biopsy to rule out inflammatory breast cancer or Paget's disease. 1, 2

Critical First Step: Rule Out Malignancy

Before treating any breast skin changes as a simple rash, you must exclude serious disease:

• Any unusual skin changes around the breast may represent serious disease and require evaluation - inflammatory breast cancer (IBC) should be considered when dermal edema (peau d'orange) and breast erythema are present 2
• IBC is a clinical diagnosis requiring erythema and dermal edema of one-third or more of the breast skin with a palpable border to the erythema 2
• Initial evaluation begins with bilateral diagnostic mammogram with or without ultrasound imaging, even if you suspect a benign rash 2
• If imaging is normal (BI-RADS 1-3) but skin changes persist, punch biopsy should still be performed 2

Treatment Algorithm for Benign Under Breast Rash

For Mild to Moderate Rash (Non-Pustular)

• Apply topical low-to-moderate potency corticosteroids to affected areas - hydrocortisone cream can be applied 3-4 times daily 3, 1
• Use alcohol-free moisturizers containing 5-10% urea twice daily to maintain skin barrier function 4
• Keep the area clean with gentle, non-irritating cleansers and avoid frequent washing with hot water 4
• Ensure the area stays dry - moisture and friction under the breast create ideal conditions for rash development 5

For Pustular or Infected-Appearing Rash

• Obtain bacterial cultures before starting antimicrobial therapy if infection is suspected (painful lesions, yellow crusts, discharge, pustules) 3, 4
• Initiate oral tetracycline antibiotics for 6 weeks, such as doxycycline 100 mg twice daily or minocycline 50 mg twice daily, combined with topical corticosteroids 3
• Administer appropriate antibiotics based on culture sensitivities for at least 14 days if bacterial superinfection is confirmed 4
• Consider flucloxacillin for Staphylococcus aureus infections or phenoxymethylpenicillin for β-hemolytic streptococci 4

For Severe or Refractory Rash

• Add systemic corticosteroids, such as prednisone 0.5-1 mg/kg body weight for 7 days with weaning dose over 4-6 weeks 3
• Consider isotretinoin at low doses (20-30 mg/day) for resistant cases 3
• Reassess after 2 weeks of initial therapy - if no improvement or worsening, escalate treatment or consider alternative diagnoses 4

Common Pitfalls to Avoid

• Never delay diagnostic evaluation with imaging and potential biopsy by treating empirically with antibiotics alone - antibiotics may or may not be given depending on clinical suspicion for infection, but should not delay diagnostic evaluation 2
• Failure to obtain cultures before starting antimicrobial therapy can lead to diagnostic challenges and inappropriate treatment 3, 4
• Do not assume all under breast rashes are simple intertrigo - the differential includes candidiasis, bacterial infection, contact dermatitis, and importantly, malignancy 2
• Avoid skin irritants including harsh soaps, solvents, and over-the-counter anti-acne medications that can worsen the rash 4

When to Refer

• Refer to dermatology if the rash does not respond to first-line treatment measures 4
• Refer to breast specialist if imaging shows BI-RADS category 4 or 5 findings, or if benign biopsy results don't correlate with persistent clinical findings 2
• Consider breast MRI, repeat biopsy, and consultation with breast specialist if skin biopsy is benign but clinical suspicion remains 2