Treating nipple yeast infection

How do I treat a nipple yeast infection?

Nipple yeast infections can be treated with an antifungal cream or antifungal pills. Our clinic uses a cream if the infection is recent, the skin is not too red, there are no cracks in the nipple, and the pain is not too severe. If there is no improvement after 10 days or if the rash is moderate or severe, the nipples are cracked, or the pain is severe, we recommend antifungal pills. Fluconazole pills are safer than others. If there is no improvement after two weeks, the diagnosis may be wrong or the yeast may be resistant to fluconazole. Once treated, mild infections are usually gone within three weeks. Severe infections can take four. They may also be helped along with mild steroid cream. Nipple cracks may be treated with purified lanolin and a non-stick dressing, but if they are infected by bacteria, mothers will need an antibiotic ointment or oral antibiotics.

A) Treating nipple yeast infection

The diagnosis of nipple yeast infection is made based on the type of pain mothers feel and the changes in the appearance of the central areola and where the nipple meets the areola (nipple bottom). Once diagnosed, nipple yeast infection requires treatment.

Nipple yeast infection is treated with an antifungal medication. This can be in a cream form or given as a pill (oral treatment). Cracks must also be treated. The pain should steadily improve. Once well, mothers can also consider preventing further infections.

Although you may be tempted to put purified lanolin or other products on the flaky areas of the areola, don’t. The flaking is not caused by dry skin but by the Candida infection. Purified lanolin keeps the nipple and areola moist and may encourage Candida growth. Purified lanolin should only be used on nipple yeast cracks as outlined below.

If the baby has visible thrush, it should always be treatedTreating the baby with antifungal preparations when the baby does not have thrush is not usually helpful.

Please see your health-care providers if you have a nipple yeast infection. They can help confirm the diagnosis, prescribe medication, and ensure your baby is growing well during this time.

B) Antifungal cream

1) When to use an antifungal cream

We recommend using an antifungal cream if:

  • The infection has been present for under one month.
  • The skin of the areola is not too red and swollen.
  • There are no cracks at the nipple bottom.
  • The pain is not too severe.

2) How to use an antifungal cream

Miconazole (2%) and clotrimazole (1%) creams are commonly used antifungal preparations that are effective against Candida. Both can be bought without a prescription. Antifungal creams is used as follows:

  1. Right after each feeding, rub the cream into the affected parts of the nipples and areolas.
  2. Ensure that you apply the cream to the nipple bottom, since Candida is most active in this area.
  3. To minimize the amount of cream that the baby may swallow, only use as much cream as can be rubbed in.
  4. Just before the next feeding:
    1. Wash the cream off, using a little breast milk.
    2. Wipe the area dry with a soft, clean cloth.
  5. Mothers should feel considerably better in 10 days and normal in three weeks.

In addition to being antifungals, both miconazole and clotrimazole have some ability to kill skin bacteria that can cause nipple infections (Alsterholm 2010).

3) Risks of antifungal creams

There are a few reports of individuals being allergic to miconazole and clotrimazole (Abhinav 2015; Fernandez 1996). Ensure that you do not react to these products.

Only small amounts of miconazole and clotrimazole appear to be absorbed through the skin (Eichenfield 2007).

C) Antifungal pills

1) When to use pills

Our clinic uses oral treatment with antifungal pills if:

  • The cream did not have any effect after 10 days.
  • The pain and rash is increasing while using cream.
  • The mother is allergic to the cream.
  • The rash on the areola is moderate or severe.
  • There are cracks at the bottom of the nipple.
  • The pain is severe.

2) Why we use fluconazole pills

While there is very little research supporting the use of fluconazole for the treatment of nipple yeast, we have found it useful and this is a widely accepted practice.

Compared with other antifungal pills, fluconazole:

  • Is well tolerated by premature babies.
  • Is considered compatible (poses very little or no risk to the baby) with breastfeeding. 
  • Is safer than other antifungal pills.

3) How to use fluconazole pills

The usual dose for fluconazole is 200 milligrams right away and then a further 100 mg each day for the next 13 days. 

It is rare that fluconazole is needed for more than two weeks and we have never used it for more than four weeks. After two weeks, almost all mothers are much better. If they still have minor symptoms, they can use an antifungal cream for a further one to two weeks.

If symptoms do not improve within two weeks of treatment, the type of Candida present may be resistant to fluconazole. However, more than 90% of Candida can be treated with fluconazole, raising the possibility that the diagnosis of nipple yeast infection is not correct (Chen 2017; Quindós 2014; Wang 2016).

4) Risks of fluconazole

Fluconazole can cause headaches, dizziness, sleepiness, tummy upset or pain, or an allergic reaction.

Rarely, fluconazole can cause serious heart rhythm abnormalities (Chakravarty 2009; Gibbs 1999). It should not be combined with domperidone, a medication used to increase milk supply, as this further increases the risk of such rhythm abnormalities (Ehrenpreis 2017). Fluconazole can increase or decrease levels of some medications (Quindós 2019).

Please discuss the risks and benefits of using fluconazole with your health-care providers. If you are taking other medication, ensure that they can be combined with fluconazole.

D) Steroid skin preparations

Rarely, the nipple yeast rash can be so bad that in addition to fluconazole, mothers need a steroid skin preparation for a week or two to settle pain and skin inflammation. It is important to wash this off before the baby feeds with breast milk and using a soft, clean cloth. 

E) Treating nipple yeast cracks

If you have cracks at the bottom of the nipple caused by a nipple yeast infection:

  • Take the pills as described above.
  • After each feeding, apply a small amount of purified lanolin ointment just to the cracks.
  • Cover this with a non-stick dressing.
  • Do not air-dry the cracks.
  • Stop using the purified lanolin and dressing as soon as the cracks are healed.
  • Watch for increasing pain or discharge, since these can be signs of a bacterial infection and will need treatment with antibiotics.

Nipple cracks are usually healed within two weeks. Nipple cracks that are infected, have been present for more than two weeks, or are very deep may take longer.

F) Treatment takes time

The treatment of a nipple yeast infection is effective but takes time, depending on how bad the infection is.

If mothers have only pain and no rash, the symptoms should be gone within three weeks of starting treatment. If the infection is severe with cracks, it can take four weeks. If there is no improvement at one week after starting treatment, please see your health-care providers to confirm the diagnosis and review the treatment.

Mothers who have a particularly severe nipple yeast infection or one that is not settling with treatment may have other health problems. It is also possible that the diagnosis is wrong.

G) Other nipple yeast infection treatment

A variety of other products have been used to treat nipple yeast infection. Some may be ineffective and others may cause harm. 

1) Nystatin

Nystatin is an antifungal. It is available in cream form to treat skin infections and in liquid form to treat thrush in the baby’s mouth. Neither form is very effective. Some mothers are told to use nystatin liquid to treat both their nipple yeast infection and their baby’s thrush. The suspension is unlikely to penetrate the mother’s skin and using it in this way is pointless. It is also rather sticky and unpleasant to use in this way.

2) Gentian violet and tea tree oil

Gentian violet, a purple dye, has numerous possible side effects and tea tree oil can cause skin irritation. 

3) Grapefruit seed extract

Grapefruit seed extract is purported to treat yeast infections. However there are a number of reasons to not use it. 

Grapefruit seed extract has never been tested in a clinical trial on people. 

Multiple studies of its components have found grapefruit seed extract to be contaminated with various synthetic antimicrobial chemicals such as triclosan and benzalkonium chloride (Avula 2007; Bekiroglu 2008; Ganzera 2006; Sakamoto 1996). Any antimicrobial activity is most likely due to these additives and not the extract itself (Cardellina 2012; Takeoka 2001; von Woedtke 1999).

Even more concerning are the possible side effects of these compounds which ranges from eye, skin, and lung irritation, to causing reproductive and developmental defects in infants (triclosan) (Weatherly 2017).

References

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Alsterholm M, Karami N, Faergemann J. Antimicrobial activity of topical skin pharmaceuticals - an in vitro study. Acta Derm Venereol. 2010 May;90(3):239-45

Avula B, Dentali S, Khan IA. Simultaneous identification and quantification by liquid chromatography of benzethonium chloride, methyl paraben and triclosan in commercial products labeled as grapefruit seed extract. Pharmazie. 2007 Aug;62(8):593-6

 
Bekiroglu S, Myrberg O, Ostman K, et al. Validation of a quantitative NMR method for suspected counterfeit products exemplified on determination of benzethonium chloride in grapefruit seed extracts. J Pharm Biomed Anal. 2008 Aug 5;47(4-5):958-61
 
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Chakravarty C, Singh PM, Trikha A, Arora MK. Fluconazole-induced recurrent ventricular fibrillation leading to multiple cardiac arrests. Anaesth Intensive Care. 2009 May;37(3):477-80
 
Chen YC, Kuo SF, Chen FJ, et al. Antifungal susceptibility of Candida species isolated from patients with candidemia in southern Taiwan, 2007-2012: impact of new antifungal breakpoints. Mycoses. 2017 Feb;60(2):89-95
 
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