What to do for a burning rash between the breasts?

Management of Burning Rash Between the Breasts

First rule out inflammatory breast cancer with bilateral diagnostic mammogram (with or without ultrasound) before treating any unusual breast skin changes, even if you suspect a benign rash. 1

Critical Initial Evaluation

• Any persistent erythema or skin changes around the breast requires imaging evaluation - inflammatory breast cancer (IBC) presents as erythema and dermal edema affecting one-third or more of breast skin with a palpable border 1
• If imaging is normal but skin changes persist beyond initial treatment, perform punch biopsy 1
• Never delay diagnostic workup by treating empirically with antibiotics alone - antibiotics may be given for suspected infection but should not postpone imaging and potential biopsy 1

Treatment Algorithm for Benign Inframammary Rash

First-Line Management

• Apply topical low-to-moderate potency corticosteroids (hydrocortisone cream) 3-4 times daily to affected areas 1, 2
• Use alcohol-free moisturizers containing 5-10% urea twice daily to restore skin barrier function 1, 2
• Keep the area dry - moisture and friction under the breast create ideal conditions for rash development 1
• Clean with gentle, non-irritating cleansers and avoid frequent washing with hot water 1, 2

If Bacterial Superinfection is Suspected

Look for these specific signs: failure to respond to initial treatment, painful skin lesions, pustules extending to arms/legs/trunk, yellow crusts, or discharge 3

• Obtain bacterial culture before starting antibiotics 3, 2
• Administer antibiotics for at least 14 days based on sensitivity results 3, 2
• Consider flucloxacillin for Staphylococcus aureus or phenoxymethylpenicillin for β-hemolytic streptococci 2

For Persistent or Worsening Rash (Grade 2-3)

• Continue topical corticosteroids and escalate to medium-high potency if needed 3, 2
• Add oral tetracycline antibiotics (doxycycline 100mg twice daily OR minocycline 50mg twice daily) for at least 6 weeks 3, 2
• Add oral antihistamines for symptomatic relief 2
• Reassess after 2 weeks - if no improvement, proceed to next step 3

For Severe or Refractory Cases

• Consider short course of systemic corticosteroids: prednisone 0.5-1 mg/kg body weight for 7 days with tapering over 4-6 weeks 3, 2
• Refer to dermatology for consideration of skin biopsy or alternative diagnoses 2

Common Pitfalls to Avoid

• Do not assume all under-breast rashes are simple intertrigo - the differential includes candidiasis, bacterial infection, contact dermatitis, nipple eczema, and critically, malignancy 1, 4, 5
• Avoid skin irritants including harsh soaps, OTC anti-acne medications, solvents, and disinfectants 3, 2
• Do not use excessive sun exposure on affected areas 3, 2
• Recognize that isolated breast erythema can be benign but may take 4-13 weeks to heal, and therapeutic interventions including antibiotics or steroid creams may not accelerate resolution 6

When to Refer

• Refer to breast specialist if imaging shows suspicious findings, or if benign biopsy results don't correlate with persistent clinical findings 1
• Consider breast MRI, repeat biopsy, and breast specialist consultation if skin biopsy is benign but clinical suspicion for malignancy remains 1
• Refer to dermatology for rashes not responding to first-line treatment, suspected autoimmune skin disease, or cases requiring definitive diagnosis via biopsy 2

Special Considerations for Lactating Patients

• Both topical corticosteroids and calcineurin inhibitors are considered safe during lactation 4
• Consider nipple protection devices for nursing women and adjust latch/suck positioning if needed 4
• Warm water compresses, black tea compresses, or commercially available tannin-containing topicals can provide comfort 4