Severe Cystic Acne While Breastfeeding

I met patient, Amanda (not her real name), at an urban academic center in Northeastern United States, postpartum, with her 2-day-old infant son. She was breastfeeding and expressed that things were going well, but she was worried about what was “below the surface.” During her prior breastfeeding experience, she had developed severe cystic acne, and now, she was starting to feel that cysts were beginning to erupt (Figures 1-4).

Figure 1.

Photographs from Oct 9, 2015, at 3 weeks postpartum.

Figure 2.

Photographs from Oct 16, 2015, at 4 weeks postpartum.

Figure 3.

Photographs from Oct 26, 2015, about 5 weeks postpartum.

Note. Amanda was still breastfeeding but only about 2–3 times per day. The cyst behind her ear was particularly painful. She said that it appeared in the exact same spot while breastfeeding both babies. When she felt it erupting the second time, she knew she would have to wean.

Figure 4.

Photographs from Nov 17, 2015, at 8 weeks postpartum.

Note. 2 weeks after she had stopped breastfeeding. “These photos of my back are from yesterday. Tough to see from the photos but these guys are pretty huge. I have a few more like them on my chest, and then some scattered on my upper arms and shoulders. The skin on my face is starting to clear up though. I have only two cysts that are going away, and don’t feel any new ones brewing under my skin.”—Amanda

Six years ago, while breastfeeding her first baby, the skin on Amanda’s face, trunk, and back became marred with subcutaneous cysts which started at 2 weeks postpartum. She described the cysts as quarter-sized blisters that would weep yellow fluid and then scab over. The cysts were extremely painful, and they caused her clothing to stick to her back after sleeping. They were unsightly, and she began to avoid leaving the house for fear of people staring at her. She developed feelings of hopelessness and despair and believes she suffered postpartum depression related to this condition.

At her request, her obstetrician did blood work to check her hormone levels, and she was told her testosterone levels were elevated. Her physician ruled out polycystic ovarian syndrome (PCOS), and no further hormone testing was suggested. She tried alternative therapies in hope that anything would help. For example, she saw an acupuncturist who provided needle treatment and prescribed daily doses of Chinese herbal remedies. She describes the information and recommendations from physicians as follows:

She looked to the internet for information. Per “mommy blogs,” Amanda considered the theory that it was a “prolactin allergy.” Her obstetrician also theorized it was related to hormones of lactation.

With her first baby, symptoms began to subside once breastfeeding ceased. She stopped breastfeeding around 2 months, and it took about another 6 weeks for her skin to clear and new lesions to stop appearing. Her doctor prescribed tetracycline and tazarotene cream (Tazorac, Allergan) and began ethinyl estradiol and norgestimate oral contraceptives (Ortho Tri Cyclen, McNeil-Janssen Pharmaceuticals, Inc.) to help regulate her hormones.

With this baby, John, born September 19, 2015, she states,

She stopped breastfeeding at 6 weeks and expressed sadness, stating that they both really enjoyed it. Although advised to see an endocrinologist, she declined. She described weaning as a gradual, 3-week transition with breastfeeding and giving formula bottles. At 8 weeks postpartum, she was still having new lesions, but smaller, about a half inch in size and less cystic. She said the cysts were considerably worse with her first baby than her second and that they got progressively worse the longer she breastfed. She weaned before that could happen again.