Steroid skin preparations

Should I use a steroid cream on my nipples and areolas?

Steroid preparations are prescribed by health-care providers and are used to treat various skin problems. They can be used by breastfeeding mothers to treat areolar eczema, milk pimples, and nipple yeast. They come in various forms and strengths. They can have side-effects and should be used in the smallest amounts, for the shortest times, and in the weakest strengths needed to be effective. They should always be washed off before breastfeeding or expressing. Steroid preparations can cause thinning of the skin, skin breakdown, infections, allergic reactions, and an increased risk of nipple yeast. If they are swallowed by breastfeeding babies, they can cause hormone abnormalities, decreased growth rates, elevated blood sugar levels, kidney abnormalities, and elevated blood pressure, among other problems.

A) Describing steroid preparation

1) Reasons for using a steroid preparation

Steroids decrease inflammation and are used in preparations for various skin problems. Steroid preparations can be used by breastfeeding mothers for:

Steroids can be combined with antibiotics and antifungal agents to create combination ointments such as all-purpose nipple ointment [APNO]. We have these useful in treating small, infected, late-onset wounds that do not respond to other treatment. 

Steroid preparations are usually prescribed by health-care providers.

2) Steroid strength

There are many types of steroids with different strengths. They have been classified into seven groups, ranging from least potent to ultra-high strength (Ference 2009).

3) Steroid forms

Steroid skin preparations come in various forms:

  • Lotions
  • Creams
  • Ointments
  • Gels
  • Foams
  • Shampoo

Ointments are greasy, which increases the absorption of the steroid and generally results in good coverage of an area. Ointments are preferred if the skin is open or weeping as they provide more moisture to the wounds.

Creams are mixtures of oil and water. They are not as strong as ointments and contain preservatives that can sting.

Lotions contain alcohol, which can also sting. 

4) The use of steroid preparations by breastfeeding mothers

The choice of steroid preparation depends on:

  • The problem being treated.
  • The location of the problem.
  • How often it needs to be applied.
  • How long it needs to be used.
  • The risks of side-effects.

a) Strength and form

In general, low to moderate strength steroids are effective as the breast skin is thin and responds well to steroids. Strong preparations should not be used on the breast, areola, or nipple. 

We have found that mothers report ointments most soothing and prefer these over lotions and creams.

b) Safety for the baby

Skin preparations used on the nipple and areola can be swallowed by breastfeeding babies. They have many ingredients which will be indicated on the container. Please review these with your health-care providers to ensure they are not toxic to the baby. 

To minimize the use of worrisome ingredients such as petrolatum and mineral oil, mothers can use a preparation made by combining modified lanolin and an appropriate steroid powder. This is generally done by a specialist (compounding) pharmacist. This may be more costly than pre-made preparations. 

B) Use of steroid preparations on the breast

Steroid preparations can be transferred to the baby’s skin by contact with the mother’s skin. When steroid preparations are used for breast skin problems, only mild to moderate strength preparations should be used. The baby’s skin should not touch the area of the breast where the preparation is applied. This can be prevented by keeping the area covered with clothing or by a cloth.

Creams or lotions may be preferred as ointments may be more persistent on the mother’s skin and more likely to be transferred to the baby.

Steroid preparations on the breast should be:

  • The weakest strength needed to be effective. 
  • The smallest amounts needed to be effective.
  • Applied in a light coating.
  • Used for the shortest time necessary to treat the problem.

C) Use of steroid preparations on the nipple and areola

The skin of the areola is very thin and responds well to lower-strength steroid preparations, even if the problem looks severe. Only mild to moderate strength preparations should be used and only when necessary.

Steroid preparations should be:

  • The weakest strength needed to be effective with milk pimples tending to need moderate strength steroids. The strength used to treat areolar eczema and nipple yeast is determined by their severity.
  • The smallest amounts needed to be effective.
  • Applied in a light coating.
  • Covered with a non-stick dressing to keep from being wiped off in the breast pad, bra, or clothing.
  • Always washed off with expressed breast milk and wiped with a soft cloth before every breastfeeding or expressing.
  • Used for the shortest time necessary to treat the problem.

D) Risks with use of steroid preparations

Steroid preparations used on the areola and nipple can have side-effects for both mother and baby. The stronger the steroid, the longer it is used, and the larger the amounts that are used, the more likely it is to cause side-effects.

1) Risk of steroid preparations for the mother

Side-effects from steroid use on skin include (Ference 2009):

  • Thinning and weakening of the skin
  • Skin breakdown
  • Skin blood vessel changes
  • Infections (bacteria and yeast)
  • Allergic reactions
  • Changes of skin colouring

2) Risk of steroid preparations for the breastfeeding baby

Skin preparations used on the nipple and areola can be swallowed by breastfeeding babies. They have many ingredients which will be indicated on the container. Please review these with your health-care providers to ensure they are not toxic to the baby. 

Steroid preparations need to be carefully washed off before use. If taken internally, steroids can cause dangerous effects in babies and children (De Stephano 1983):

  • Hormone abnormalities
  • Decreased growth rate in children
  • Elevated blood sugar levels
  • Kidney abnormalities and changes in blood salt levels
  • Elevated blood pressure
  • Changes in appearance (Cushingoid)
  • Changes in the heart rhythm

References

De Stefano P, Bongo IG, Borgna-Pignatti C, et al. Factitious hypertension with mineralocorticoid excess in an infant. Helv Paediatr Acta. 1983 May;38(2):185-9
 
Ference JD, Last AR. Choosing topical corticosteroids. Am Fam Physician. 2009 Jan 15;79(2):135-40