Prescribing for pregnancy: chronic skin diseases

Chronic skin disease is common in women of reproductive age. Although skin can improve or remain stable during pregnancy, it is also common for existing conditions to flare and for new conditions to develop. A small number of medications used to control chronic skin disease can potentially have adverse effects on the outcome of the pregnancy. This article forms part of a series on prescribing for pregnancy and highlights the importance of achieving good control of the skin disease prior to conception and during pregnancy. It emphasises the need for patient-centred, open and informed discussions around medication options to achieve good control. During pregnancy and breastfeeding each patient should be treated as an individual in accordance with the medications that are appropriate for them, their preferences, and the severity of their skin disease. This should be done through collaborative working across primary care, dermatology and obstetric services.

Nipple eczema: A systematic review and practical recommendations

The nipple is the focal point of the human breast and serves important physiological, sexual, and aesthetic purposes. It can be affected by atopic, irritant, and allergic contact eczema, which often reduce the patient's quality of life. The objective of this article is to discuss the different types of nipple eczema and highlight relevant differential diagnoses and treatment options. A systematic search of PubMed was conducted to identify and critically appraise the existing literature on the topic. All articles on nipple eczema were considered eligible, regardless of publication date, language or study design. A final of 33 manuscripts on nipple eczema remained. The scarce literature and the limited number of high-quality manuscripts impedes provision of structured data on nipple eczema. To securely reach the educative value of this manuscript, the systematic review was combined with a manual databank search and selected manual search of textbooks. The differential diagnosis of nipple eczema encompasses among others nipple psoriasis, nipple candidiasis and Paget's disease. In case of diagnostic uncertainty, swabs or biopsies are indicated. Treatment of nipple eczema needs to rapidly control the signs and symptoms of the disease, since it can have a negative effect on quality of life and can lead to premature arrest of breastfeeding. The key treatment step is starting with topical corticosteroids or calcineurin inhibitors, both of which are considered safe during lactation. Avoidance of provoking factors, such as repetitive friction, chemical agents, or allergens, can help. The use of nipple protection devices can be proposed for nursing women and sometimes adjusting of latch/suck positioning during breastfeeding is needed. Furthermore, patients should be advised to moisturize the nipple intensively and to switch to emollient wash products. Warm water compresses, black tea compresses or commercially available tannin containing topicals can provide comfort.

Nomenclature and clinical phenotypes of atopic dermatitis

Atopic dermatitis is a heterogeneous disease and resists classification. In this review, we discuss atopic dermatitis nomenclature and identify morphologic phenotypes, which will facilitate correct diagnoses and development of treatment strategies. We support using the term 'atopic dermatitis' rather than eczema, because it describes the allergic background and inflammation ('itis') as drivers of the disease. Atopic dermatitis has many morphologic manifestations that vary by topographic area affected, age, or race and require consideration in differential diagnosis. Different phenotypes based on morphology and topographic location, ethnicity, and age are discussed. A better-defined phenotype identification for atopic dermatitis will facilitate earlier and correct diagnosis of this complex condition and inform selection of the most appropriate treatment choice in an era in which targeted therapies may generate more individualized patient care.

[Pathology of the nipple-areola complex : I. Paget's disease of the nipple, variants, and differential diagnoses]

The classical Paget's disease of the nipple is histologically characterized by tumor cell infiltration originating in intraductal or invasive breast carcinoma, immunohistologically by a frequent overexpression of HER2 and clinically by eczema-like changes of the nipple and areola. Variants with different histological, immunohistological, and clinical features are observed in nonclassical forms of Paget's disease, such as isolated Paget's disease of the nipple, anaplastic Paget's disease, Paget's disease with invasion, and pigmented Paget's disease of the nipple. In the differential diagnosis of Paget's disease, benign changes have to be considered, including Toker cell hyperplasia, nipple eczema, and rare dermatoses.

Paget Disease of the Breast in Pregnancy and Lactation

Paget's disease of the breast (PDB) is a rare breast carcinoma believed to arise from an underlying in situ or invasive ductal cancer that migrates through the epidermis causing characteristic skin changes including scaling, redness, and itching of the nipple, areola, and sometimes the surrounding skin. Although Paget's may mimic benign conditions such as contact or allergic eczema and mastitis, it should remain a strong consideration in the differential diagnosis , especially in peripartum women for whom benign conditions such as bacterial mastitis from breastfeeding are common. The workup of Paget's should focus on both making the diagnosis with nipple/skin scrape cytology or punch biopsy as well as evaluating any underlying mass with mammogram, breast ultrasound , and also a core needle biopsy , if required. Treatment focuses on management of the underlying breast cancer as usual. The purpose of this chapter is to describe the presentation of PDB as well as outline an approach to its diagnosis and management, especially in the setting of pregnancy and lactation.

Skin diseases of the breast and nipple: Inflammatory and infectious diseases

Certain dermatologic conditions are unique to the breast and nipple, whereas others may incidentally involve these structures. All require a nuanced approach to diagnosis and treatment because of the functional, sexual, and aesthetic importance of this area. The lactating patient requires special management because certain treatment options are contraindicated. All dermatologic conditions involving the breast and nipple require careful evaluation because malignancy of the breast can be mistaken for a benign condition or may trigger the development of certain dermatologic conditions. The second article in this continuing medical education series reviews common and uncommon inflammatory and infectious conditions of the breast and nipple and provides insight into both the diagnosis and the treatment of this heterogeneous group of diseases. For the purposes of this article, these conditions are divided into 4 distinct categories: 1) dermatitis; 2) radiation-induced changes; 3) mastitis; and 4) miscellaneous dermatologic conditions of the breast and nipple.

Diagnosis and Management of Candida of the Nipple and Breast

Diagnosis and treatment of ductal and/or nipple candidiasis in breastfeeding women is complicated by the variety of symptoms women experience. The differential diagnosis includes candidiasis of the nipple, candidiasis of the breast, bacterial infection of either nipple or breast, and other less common problems such as Raynaud's syndrome. Diagnosis and treatment are based on history, physical examination, and presenting symptomatology because cultures of breast milk are often inconclusive. Differential diagnoses and treatment options are reviewed.