What is the recommended treatment for eczema of the nipple, particularly in breastfeeding women?

Treatment for Eczema of the Nipple

For nipple eczema, initiate treatment with topical corticosteroids or topical calcineurin inhibitors, both of which are safe during breastfeeding, combined with intensive moisturization and avoidance of irritants. 1

Initial Diagnostic Considerations

Before treating as simple eczema, rule out important differential diagnoses:

• Paget's disease of the breast presents with nipple eczema, bleeding, ulceration, and itching, and requires biopsy if clinical suspicion exists 2
• Candidal infection should be excluded, particularly in breastfeeding women with persistent nipple pain 2
• If diagnostic uncertainty exists after initial treatment failure, perform skin biopsy or swabs 1

First-Line Treatment Approach

Topical Anti-Inflammatory Therapy

Start with topical corticosteroids as the primary treatment:

• Mild to moderate potency corticosteroids (e.g., hydrocortisone cream) for initial management 2
• Moderate potency steroids (e.g., prednicarbate cream 0.02%) for more severe inflammatory lesions 2
• Both are safe during lactation and should be applied after breastfeeding to minimize infant exposure 1

Topical calcineurin inhibitors are an equally effective alternative:

• Tacrolimus 0.1% or pimecrolimus 1% can be used, particularly if concerns about steroid use exist 1, 3
• These are also safe during breastfeeding 1
• May cause initial application-site burning or stinging, which typically resolves with continued use 3

Essential Supportive Measures

Intensive moisturization is critical:

• Apply emollients at least once daily to the entire breast area 2
• Use urea- or glycerin-based moisturizers 2
• Switch to emollient wash products and avoid soaps 2, 1

Avoid irritants and allergens:

• Eliminate hot showers and excessive soap use 2
• Avoid alcohol-containing lotions or gels in favor of oil-in-water creams or ointments 2
• Identify and eliminate repetitive friction, chemical agents, or specific allergens 1

Special Considerations for Breastfeeding Women

Breastfeeding-specific interventions:

• Use nipple protection devices during nursing 1
• Adjust latch and suck positioning to reduce mechanical trauma 1, 4
• Apply warm water compresses or black tea compresses for symptomatic relief 1
• Provide effective pain control and emotional support to prevent premature weaning 4

Treatment for Pruritus

If significant itching accompanies the eczema:

• Apply polidocanol-containing creams topically 2
• Consider oral H1-antihistamines (cetirizine, loratadine, fexofenadine, or clemastine) for moderate to severe pruritus 2

When to Escalate or Refer

Refer to a dermatologist if:

• No response to mildly potent steroids after 2 weeks of appropriate treatment 2
• Diagnostic uncertainty persists 2
• Suspicion of Paget's disease or other malignancy 2
• Need for second-line treatments 2

For refractory cases, consider:

• Higher potency topical steroids (e.g., mometasone furoate) under specialist supervision 2
• Short-term oral systemic steroids for severe grade 3 erythema and desquamation 2
• Access to patch testing if allergic contact dermatitis is suspected 2

Critical Pitfalls to Avoid

Never use topical corticosteroids alone without proper diagnosis if there is any suspicion of fungal infection, as steroids can worsen fungal infections and mask the clinical presentation 5

Do not delay biopsy if nipple changes persist despite appropriate treatment, as Paget's disease can mimic eczema and is present in up to 80-90% of cases presenting with nipple eczema-like symptoms 2

Reassess after 2 weeks - if no improvement or worsening occurs, escalate treatment intensity or reconsider the diagnosis 2