Nipple Candidiasis

Nipple candidiasis is fungal infection of the nipple and areola, and sometimes the milk ducts, by Candida albicans, causing burning pain during and after feeds. It usually follows damaged nipple skin, antibiotics for the mother or infant, oral thrush in the infant, diabetes and use of steroids or contraceptives. It matters because it causes severe pain, reduced feeding and early weaning, and it passes between mother and infant, so both are treated.

• Risk factors: nipple trauma, maternal or infant antibiotics, infant oral thrush or nappy rash, diabetes, vaginal candidiasis, damp breast pads, pacifiers, steroid use, immunosuppression.
• Pain persists after the latch is corrected.
• Deep breast pain with normal skin suggests ductal involvement.

Women have burning, itching or stabbing nipple pain during feeds and for an hour or more after, with pink, shiny or flaky nipples and areolae, sometimes with white patches, tiny blisters or cracks. Deep radiating breast pain suggests ductal candidiasis. The infant may have white plaques on the tongue and cheeks or a nappy rash.

• Pink, shiny, flaky or glazed nipple, or white patches.
• Infant with oral thrush (white plaques that do not wipe off easily).
• Differential diagnosis: nipple fissure, cracked nipple, bacterial infection, vasospasm, eczema, contact dermatitis, herpes simplex, psoriasis, Paget disease of the breast, subclinical mastitis, poor latch.
• Complications: cracked nipples, bacterial infection, mastitis, ductal candidiasis, nipple pain with early weaning, repeated reinfection between mother and infant.

The diagnosis is clinical, with treatment of both mother and infant.

• History of burning pain after feeds, recent antibiotics, infant thrush; inspection of the nipple, areola and infant's mouth and nappy area.
• Culture or microscopy of nipple swab or milk (potassium hydroxide preparation) if the diagnosis is uncertain or treatment fails.
• Fasting glucose or HbA1c if recurrent; high vaginal swab if vaginal symptoms.
• Observation of a feed for latch; biopsy for nipple lesion not healing at 3 weeks.

The principle is to treat the mother and infant at the same time with antifungal drugs, and to keep the nipples dry.

• Supportive:
  • Continue breastfeeding.
  • Wash hands after nappy changes and before and after feeds.
  • Rinse the nipple with water after feeds and air dry.
  • Change breast pads after each feed.
  • Wash bras, towels and clothing at 60 degrees Celsius and dry in the sun or a hot dryer.
  • Boil pump parts, teats and pacifiers for 20 minutes daily.
  • Reduce sugar in the diet.
  • Avoid antibiotics where not essential.
• Pharmacological:
  • Mother: miconazole 2 percent cream applied thinly to the nipple and areola after each feed 3 to 4 times daily for 14 days (or 7 days after symptoms clear), or clotrimazole 1 percent cream applied after each feed for 14 days.
  • Infant: nystatin oral suspension 100,000 units/mL, 1 mL placed in the mouth 4 times daily after feeds, for 14 days (and for 7 days after the thrush clears).
  • Nappy rash: miconazole 2 percent cream applied to the nappy area 2 to 3 times daily for 14 days.
  • Persistent or ductal candidiasis: fluconazole 400 mg oral as a single loading dose then 100 mg oral once daily for 14 to 21 days.
  • Gentian violet 0.5 percent solution applied to the nipple once daily for 3 to 4 days (maximum 7 days).
  • Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
  • Ibuprofen 400 mg oral 8-hourly with food for pain.
• Procedures: none.
• Special groups: infants with severe thrush, poor feeding or fever are referred; diabetic women have glucose control; women taking drugs that interact with fluconazole (warfarin, phenytoin, sulfonylureas) have doses reviewed; fluconazole 100 mg once daily is compatible with breastfeeding in term infants.
• Red flags: fever above 38.5 degrees Celsius, cracked bleeding nipple with pus, deep breast pain lasting beyond 2 weeks of treatment, infant refusing feeds or not gaining weight, extensive oral thrush with fever, nipple lesion not healing at 3 weeks.
• Follow-up: review at 1 week and 2 weeks; infant weight at 1 week; culture results; repeat treatment of both mother and infant if recurrence; biopsy for nonhealing lesion.