What is the treatment for breast eczema?

Treatment of Breast Eczema

Start with topical corticosteroids applied once or twice daily to the affected breast area, using the least potent preparation that controls symptoms—typically a mild to moderate potency corticosteroid like hydrocortisone 1-2.5%—combined with liberal emollient use. 1, 2

First-Line Treatment Approach

Topical Corticosteroids

• Apply mild to moderate potency topical corticosteroids (hydrocortisone 1-2.5%) to breast eczema once or twice daily, as the breast and nipple area have thinner skin where potent steroids carry higher risk of skin atrophy. 1, 2
• Once-daily application of potent topical corticosteroids is as effective as twice-daily application for treating eczema flare-ups, so you can confidently use once-daily dosing to minimize steroid exposure. 3
• Use the least potent preparation required to keep the eczema under control, and implement "steroid holidays" (short periods without steroids) when possible to reduce side effects. 4, 1
• Very potent and potent corticosteroids should be used with caution for limited periods only in this location due to increased risk of skin thinning. 1

Essential Emollient Therapy

• Liberal use of emollients is the cornerstone of maintenance therapy and must be applied regularly, even when eczema appears controlled. 1
• Apply emollients after bathing to provide a surface lipid film that retards water loss. 1
• Switch to soap-free cleansers and avoid alcohol-containing products on the breast area. 1, 5
• Patients should moisturize the nipple and breast intensively throughout treatment. 2

Alternative First-Line Option

• Topical calcineurin inhibitors can be used as an alternative to corticosteroids and are considered safe during lactation, making them particularly useful for nursing women with nipple eczema. 2

Managing Specific Symptoms

Pruritus Control

• Prescribe sedating antihistamines (such as diphenhydramine) for nighttime use only to help with sleep disruption from itching—their benefit comes from sedation, not direct anti-pruritic effects. 4, 1
• Non-sedating antihistamines have little to no value in atopic eczema and should not be used. 4, 1
• Large doses of antihistamines may be required, and daytime use should be avoided. 4

Adjunctive Comfort Measures

• Warm water compresses, black tea compresses, or commercially available tannin-containing topicals can provide comfort for breast eczema. 2

Special Considerations for Nursing Women

• Both topical corticosteroids and calcineurin inhibitors are considered safe during lactation. 2
• Use nipple protection devices for nursing women to reduce friction and irritation. 2
• Adjust latch/suck positioning during breastfeeding if needed to minimize trauma. 2
• Avoidance of provoking factors such as repetitive friction, chemical agents, or allergens is essential. 2

Managing Secondary Infections

Bacterial Infection

• Watch for signs of secondary bacterial infection: increased crusting, weeping, or pustules. 1, 5
• Flucloxacillin is the first-line oral antibiotic for Staphylococcus aureus, the most common pathogen in infected eczema. 4, 1
• Use erythromycin in patients with penicillin allergy or flucloxacillin resistance. 4
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not withhold steroids when infection is present. 1

Viral Infection (Eczema Herpeticum)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 1, 6
• Initiate oral acyclovir early in the disease course for outpatients. 4, 1
• In ill, feverish patients, administer acyclovir intravenously immediately. 4, 1, 6

Differential Diagnosis Considerations

Before treating as eczema, consider and rule out:

• Nipple psoriasis (well-demarcated plaques with silvery scale). 2
• Nipple candidiasis (satellite lesions, history of recent antibiotics). 2
• Paget's disease of the breast (unilateral, persistent, non-responsive to treatment)—if diagnostic uncertainty exists, perform a biopsy. 2

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly to ensure adherence. 4, 1
• Avoid very potent corticosteroids on the breast and nipple area where risk of atrophy is higher due to thinner skin. 1, 5
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible. 1

When to Refer or Escalate

• Failure to respond to moderate potency topical corticosteroids after 4 weeks warrants referral to dermatology. 1, 5
• Suspected eczema herpeticum requires immediate emergency treatment. 1
• Need for systemic therapy or phototherapy indicates specialist referral. 1
• Diagnostic uncertainty requiring biopsy (to rule out Paget's disease or other conditions) necessitates specialist evaluation. 2