Infected nipple damage

Why is the pain from my nipple damage getting worse?

If the skin on the nipple is broken, bacteria can enter and cause an infection. When this happens, breastfeeding becomes more painful each day. The nipple may look red and swollen and mothers may notice dead skin or pus. It may also be increasingly painful to touch and the amount of damage may increase. Sometimes it leads to mastitis, an infection in the breast. If a mother’s nipples are clearly infected or she has mastitis, the treatment is with antibiotic pills. Antibiotic ointments and antibacterial wound care products are safer but may be less effective. There is no need to stop breastfeeding, but ointments or wound care products may need to be washed from the nipple before a feed.  

A) How bacterial infections begin

Healthy skin prevents bacteria that live on the skin from going deeper and causing infection. When nipples are damaged for any reason, this skin barrier is broken and we develop an infection. Bacteria have many ways of evading our defences and advancing and this, combined with our body’s reaction to the infection, can result in further skin damage.

Staphylococcus aureus (S. aureus) is a common cause of skin infection and can damage skin by releasing toxins (Amir 2013; Bukowski 2010). Some types of S. aureus are resistant to numerous antibiotics such as antibiotic methicillin, making infections harder to treat (Kato 2018).  

Many mothers carry this bacterium on their nipples. Not surprisingly, S. aureus is the most common cause of nipple infections, mastitis, a bacterial infection of the breast, and breast abscesses, a complicated infection of the breast (Livingstone 1996).  

Mothers are at an increased risk of infection if they are:

  • Diabetic.
  • Have a weakened immune system because of medication or illness.
  • Have low levels of red blood cells (anemia).
  • Are not eating enough protein.

Please see your health-care providers if you have nipple damage.

B) Signs of nipple infection with bacteria

1) Common signs of nipple infection

There are certain signs common to most bacterial infection:

  • Pain
  • Warmth
  • Redness
  • Swelling
  • Loss of function

Nipple infections will often ooze pus which is a yellow or white, creamy, thick liquid that contains bacteria, white blood cells, and dead tissue. It may also be bloody. It will often cause sticking to the breast pad or bra.

Infection can be very obvious and aggressive, as is common soon after the birth of the baby, or it can fester slowly, as with a pressure sore from teeth.

A breast infection (mastitis, abscesses) often results from infected nipple damage.

2) The progression to nipple infection soon after the baby’s birth

Nipples are most likely to become infected with bacteria shortly after the baby’s birth, since this is when mothers are most likely to have nipple damage.

A typical pattern of infection soon after the baby's birth is as follows:

  1. On Days 1 and 2 after birth, the nipple becomes damaged, allowing bacteria to penetrate the top layers of skin and release toxins that further damage the skin. Mothers notice more blistering, scabbing, or dead skin.
  2. By Day 3 onward, the nipple may:
    1. Have dead yellow skin or missing skin.
    2. Have many small puncture-like wounds.
    3. Look red and swollen.
    4. Ooze yellow or bloody pus that makes the nipple stick to a breast pad.
  3. Mothers may develop mastitis, typically in the second week after the baby starts breastfeeding and may progress to an abscess.

Until treated, nipple sensitivity and the pain when breastfeeding increases each day. The area of damage may grow and become deeper. 

Many questions remain about the best and safest prevention and treatment of infected nipple damage.

C) Managing and treating bacterial infection of the nipples

1) Breastfeeding with infected nipples

As with mastitis, an infection of the breast, there is no need to stop breastfeeding because of infected nipple damage.   

Rather mothers should:

  • Be treated with antibiotic pills or antibiotic or antibacterial wound care products.
  • Consider continuing to breastfeed.
  • Use appropriate wound care products and covers until the damage is healed.
  • Manage their pain.

2) Antibiotic pills

Antibiotic pills are used if the nipples are clearly infected or if the mother has developed mastitis or an abscess (Livingstone 1999). The antibiotics cloxacillin or cephalexin are reasonable first choices. The exact choice of an antibiotic and its availability vary among regions and countries.

If the nipples show some of the above signs but are not clearly infected, the decision becomes more difficult. Oral antibiotics pose risks, including:

  • Allergic reactions
  • Promotion of antibiotic resistance in bacteria
  • Elimination of good bacteria, allowing harmful ones to grow

3) Antibiotic or antibacterial wound care products

Antibiotic ointments such as those containing mupirocin or antibacterial products such as medical grade honey are safer but may also be less effective (Livingstone 1999).

If the infection does not clear with an ointment, an oral antibiotic may be needed.

4) Testing for bacteria

If your nipple damage is not responding to antibiotics, your health-care providers may want to test the bacteria growing on the nipples or in the milk. This can help decide which antibiotic to use. However, there are many bacteria on the nipple and in milk and the results may not identify the type of bacteria causing the infection.

D) Mastitis

Severe mastitis of the left breast. The nipple has deep damage which has become infected and allowed bacteria to enter the breast.

Nipple damage makes breast infection (such as mastitis and abscesses) much more likely. This is most common in the second week after the baby’s birth but can happen any time until the nipples are completely healed.

We recommend that mothers who have nipple damage that is not infected or was infected but is no longer, keep a prescription on hand for oral antibiotics. This is only filled if they develop mastitis. Mastitis comes on very quickly and unpredictably and can make mothers severely ill. It is important to treat it early to minimize the illness.

E) Yeast infection

Some mothers who develop cracks from a nipple yeast infection may develop mastitis as the cracks become infected with bacteria as well as yeast.

Conversely, some mothers with nipple damage also develop a yeast infection as the treatment for nipple damage (moisture; antibiotics) can encourage the growth of yeast. 

Nipple yeast must be treated.

F) Biofilms

Some bacteria create a coating (biofilm) out of sugars and proteins that acts as a shield to protect the bacteria from the body’s immune system and from antibiotics (Del Pozo 2018). For healing to occur, these coatings need to be disrupted.

In theory, nipple damage that is not healing or repeated episodes of mastitis may be signs of a biofilm. Breastfeeding and expressing likely prevent biofilms from developing on the nipple. If there is a concern about biofilms, washing once or twice a day with sterile water and soft, clean cloth before applying a wound care product may help break down the biofilm. Medical grade honey can be useful for treating infections when biofilms are present.

We have not found it necessary to treat biofilms. More research on the topic is needed.

References

Amir LH, Donath SM, Garland SM, et al. Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open. 2013 Mar 9;3(3)
 
Bukowski M, Wladyka B, Dubin G. Exfoliative toxins of Staphylococcus aureus. Toxins (Basel). 2010 May;2(5):1148-65
 
Del Pozo JL. Biofilm-related disease. Expert Rev Anti Infect Ther. 2018 Jan;16(1):51-65
 
Kato H, Ide K, Fukase F, et al. Polymerase chain reaction-based open reading frame typing (POT) method analysis for a methicillin-resistant Staphylococcus aureus (MRSA) outbreak through breast-feeding in the neonatal intensive care unit. IDCases. 2018 Feb 21;12:1-3
 
Livingstone V, Stringer LJ. The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study. J Hum Lact. 1999 Sep;15(3):241-6
 
Livingstone VH, Willis CE, Berkowitz J. Staphylococcus aureus and sore nipples. Can Fam Physician. 1996 Apr;42:654-9