Don't miss a viral infection of the nipple-areolar complex or breast skin

Viral infections of the nipple-areolar complex in the lactating breast are a rare but important condition

Clinicians should maintain a high index of suspicion for HSV in breastfeeding women with nipple pain.

Herpes simplex virus

Herpes simplex virus (HSV) on the nipple or breast may present as a small or imperceptible vesicle on an erythematous base which ulcerates, associated with axillary lymph node enlargement.

HSV may also present as a cluster of vesicles or ulcers on the nipple or breast, particularly during a primary outbreak.1-3

The lesions shed virus, and any contact with HSV during the first weeks and months of life may implicate the infant’s central nervous system, and prove fatal.4

If a lactating woman or her family members have had a herpes outbreak, whether type 1 or 2, and she presents with unilateral nipple pain

• A polymerase chain reaction (PCR) viral swab should be analysed, and the breast should be covered and kept away from the baby.

• Acylcovir or Valacyclovir is prescribed, which is safe to use while breastfeeding, hastening resolution and decreasing viral shedding.

• Pumped milk should be discarded from that breast, and good hand-washing and pump-cleansing hygiene practiced.5 6

Varicella zoster

Varicella zoster may present as a cluster of painful vesicles across the chest and breast. Herpes zoster infection can be fatal in a newborn.

• If lesions are not on the breast, breastfeeding should continue with lesions covered.

• If the lesions are on the breast, the infant should not be fed from that side and pumped milk discarded.

• If a mother experiences a herpes zoster outbreak within 48 hours after birth, the infant should not breastfeed.

Although antibodies pass through the milk, the infant also requires zoster immune globulin treatment. Antivirals are prescribed, as for HSV infection.

References

1. Quinn PT, Lofberg JV. Maternal herpetic breast infection: another hazard of neonatal herpes simplex. Medical Journal of Australia 1978;2(9):411-12.
2. Gupta S, Malhotra AK, Dash SS. Child to mother transmission of herpes simplex virus-1 infection at an unusual site. Journal of European Academy of Dermatology and Venereology 2008;22(7):878-79.
3. James SH, Whitley RJ. Treatment of herpes simplex virus infections in pediatric patients: current status and future needs. Clinical Pharmacology and Therapeutics 2010;88(5):720-24.
4. Barrett ME, Heller MM, Stone HF, et al. Dermatoses of the breast in lactation. Dermatologic Therapy 2013;26:331-36.
5. Barrett ME, Heller MM, Fullerton H, et al. Primary Herpes Simplex Virus infection of the nipple in a breastfeeding woman. https://wwwmdedgecom/dermatology/article/109374/infectious-diseases/primary-herpes-simplex-virus-infection-nipple 2016
6. Dekio S, Kawasaki Y, Jidoi J. Herpes simplex on nipples inoculated from herpetic gingivostomatitis of a baby. Clin Exp Dermatol 1986;11:664-66.