For Kim Baltzer and the mother with ringworm on the breast.....

Having a picture of this would really help!

You described the rash as being "on her right breast, on the underside of
her nipple, on the areola."  If the rash is red and inflamed looking, I
would assume the problem is candida.  I have had a similar patient and the
underside of the nipple and the adjoining areas were affected because the
nipple would fold down over the areola inside of the bra.   This folding
provided a dark moist enviornment for the candida to grow in.  Candida will
also result in skin breakdown.

You also mention that "she decided to wait a little longer before seeking
other treatment but called again after a few days because the rash had now
appeared on the other breast, in the same spot."  This sounds very much like
Candida and the fold down problem.

I would treat the Candida with antifungal cream.  I would also have her use
a cotton wick or little piece of cloth between the folded nipple and the
areola to air out the area.

The physician diagnosed ringworm.  Most ringworm is a circular rash with
some central paleness and a raised peripheral scaly edge.  The differential
diagnosis of this type of rash includes candida, numular eczema, contact
dermatitis, tinea corporis (ringworm), pityriasis rosea, drug eruptions,
erythema multiforme, erythrasma and psoriasis.

The most likely suspects would be the first three in that order.  Tinea
corporis would probably be number four.

Candida often has satellite lesions and you can check for this. Contact
dermatitis can come from creams such as vit E or antibiotic creams.  For a
patient to develop eczema,  check for a prior history of the same.   Tinea
corporis is usually caused by Trichophyton, a fungus which invades the dead
tissues of skin. Yum!

Pityriasis usually produces one initial lesion but then comes on with a
whole host of circular spots on the trunk.  You can check for drugs on
history.  This location is unusual for erythema multiforme as it is usually
on the hands, feet and mucous membranes.   Erythrasma is a bacterial
infection (Corynebacterium minutissimum)  and usually happens under the
breasts in heavy women or in groin folds.  I have not heard of it infecting
nipples but I suppose it is possible.  This could be diagnosed with a
Woods's light.  Any dermatologist would have one. Psoriasis is also possible
but not all that likely.

This patient should have a scraping done of the edge of the lesion.  You can
test the scraped skin flakes with potassium hydroxide and this will tell you
if there is candida or a dermatophyte such as Trichophyton present.

I would get a scrape as soon as possible and in the meantime she could be
started on an antifungal with some steroid added.  If it is fungal, we often
add a little steroid to settle the inflammation that goes along with fungi.
This would also help prevent further cracking.   If it is a dermatitis or
eczema, the steroid will get that.   I would wash off the cream with a
little breastmilk before nursing.

from Shirley Gross, who thinks this stuff is soooo neat!


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M. Shirley Gross M.D.,C.M., C.C.F.P., I.B.C.L.C.
Director, Edmonton Breastfeeding Clinic
Edmonton, Alberta, Canada
E mail at  <  [log in to unmask]  >
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