How should nipple eczema be treated?

Treatment of Nipple Eczema

Start with low-potency topical corticosteroids (hydrocortisone 1–2.5% cream) applied twice daily to the affected nipple, combined with intensive emollient use and avoidance of irritants—both topical corticosteroids and calcineurin inhibitors are safe during lactation. 1, 2

First-Line Topical Treatment

• Apply hydrocortisone 1–2.5% cream to the nipple twice daily as the preferred low-potency corticosteroid, since the nipple skin is thin and prone to steroid-induced atrophy and telangiectasia with more potent preparations. 1

• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) are an alternative first-line option, particularly when prolonged treatment beyond 2–4 weeks is needed or when corticosteroid side effects are a concern. 1, 2

• Both topical corticosteroids and calcineurin inhibitors are considered safe during lactation, allowing nursing mothers to continue breastfeeding without interruption. 2

• Limit continuous corticosteroid use to 2–4 weeks maximum, then implement "steroid holidays" or step down to emollients alone to minimize adverse effects. 1

Essential Adjunctive Skin Care

• Apply emollients liberally and frequently to the nipple, ideally immediately after bathing or nursing to create a protective lipid film that prevents water loss and supports barrier repair. 1

• Switch to soap-free, pH-neutral cleansers and avoid all alcohol-containing products, as these strip natural lipids and worsen dryness. 1, 3

• Warm water compresses or black tea compresses (which contain tannins) can provide symptomatic relief and comfort. 2

Avoidance of Provoking Factors

• Identify and eliminate repetitive friction, chemical irritants (including harsh soaps, perfumes, and fabric softeners), and potential allergens (such as lanolin-containing nipple creams or neomycin). 3, 2

• For nursing mothers, consider nipple protection devices (such as silicone shields) and adjust latch/suck positioning during breastfeeding to reduce mechanical trauma. 2

• Avoid wool or synthetic fabrics against the breast; wear cotton clothing next to the skin. 1

Managing Secondary Infections

• Watch for increased crusting, weeping, pustules, or failure to respond to initial treatment—these signs suggest secondary bacterial infection, most commonly Staphylococcus aureus. 1

• Prescribe oral flucloxacillin as first-line antibiotic therapy when bacterial superinfection is present, and continue topical corticosteroids concurrently rather than delaying anti-inflammatory treatment. 1, 4

• If grouped vesicles or punched-out erosions appear, suspect eczema herpeticum (a medical emergency) and initiate oral acyclovir immediately. 1, 4

Managing Pruritus

• For severe nighttime itching, add a sedating antihistamine (such as hydroxyzine or diphenhydramine) at bedtime only, as these work through sedation rather than direct antipruritic effects. 1, 4

• Non-sedating antihistamines have no proven benefit in eczema and should not be used. 1, 4

Critical Differential Diagnosis

• In any case of persistent or atypical nipple eczema that fails to respond to appropriate treatment within 4 weeks, perform scrape cytology or biopsy to exclude Paget's disease of the nipple, a malignancy that can mimic eczema clinically. 2, 5, 6

• Other differential diagnoses include nipple psoriasis (look for well-demarcated plaques with thick silvery scale), nipple candidiasis (obtain fungal swabs), and irritant or allergic contact dermatitis. 2, 6, 7

Common Pitfalls to Avoid

• Never use potent or very potent corticosteroids on the nipple, as the thin skin is highly susceptible to atrophy, telangiectasia, and other adverse effects. 1

• Do not delay topical corticosteroid treatment when secondary infection is present—continue anti-inflammatory therapy while treating the infection with appropriate systemic antibiotics. 1

• Avoid continuous corticosteroid use without breaks; implement "steroid holidays" after 2–4 weeks to prevent tachyphylaxis and local side effects. 1

• Address steroid phobia by explaining that low-potency preparations (hydrocortisone 1–2.5%) are safe when used correctly and that undertreatment leads to prolonged suffering and potential breastfeeding cessation. 1, 2

When to Refer or Escalate

• Refer to dermatology if there is diagnostic uncertainty, failure to respond after 4 weeks of appropriate first-line therapy, or need for patch testing to identify contact allergens. 1, 3

• Urgent referral is indicated if Paget's disease is suspected based on unilateral involvement, failure to respond to treatment, or atypical clinical features. 2, 6

• For nursing mothers, involve lactation consultants to provide whole-process guidance, psychological support, and individualized breastfeeding techniques that minimize nipple trauma. 8