Diagnosis and Management of Candida of the Nipple and Breast

Sharon Wiener, CNM, MPH

Disclosures

J Midwifery Womens Health. 2006;51(2):125-128. 

In This Article

Abstract and Case Presentation

Abstract

Diagnosis and treatment of ductal and/or nipple candidiasis in breastfeeding women is complicated by the variety of symptoms women experience. The differential diagnosis includes candidiasis of the nipple, candidiasis of the breast, bacterial infection of either nipple or breast, and other less common problems such as Raynaud's syndrome. Diagnosis and treatment are based on history, physical examination, and presenting symptomatology because cultures of breast milk are often inconclusive. Differential diagnoses and treatment options are reviewed.

Case Presentation

Jane,* a 35-year-old gravida 2, para 2, had a low forceps delivery 10 weeks ago. She returned to see her midwife for bilateral nipple pain during and after breastfeeding, a problem that was constant for the past 4 days. The pain was described as a burning sensation, which was sometimes so uncomfortable, she could not put anything on her nipples. She was teary-eyed and thinking of discontinuing breastfeeding. She denied itching, stabbing breast pain, or nipple pain with cold stimuli. Prior to the visit with her midwife, Jane was referred to a lactation consultant to evaluate latch assessment and breastfeeding problems. She was told the baby was sucking correctly, and she was advised to return to her clinician for a possible yeast infection.

The midwife took a comprehensive history. Jane's labor was complicated by the presence of moderate meconium, for which she received an amnioinfusion. She was group B strep positive and received three doses of penicillin during labor. Fetal heart rate monitoring revealed persistent deep variable decelerations in the second stage, which was the reason she had a vaginal operative delivery. Pediatricians were present at the birth, and the baby received deep suctioning for meconium. The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.

Jane's baby stayed in the hospital an extra day because her baby had a weight loss of more than 10%. Jane started pumping her breasts on her second day postpartum because her baby had a poor suck and needed supplemental feedings. Jane's milk came in on the third day after birth. By the time she was discharged from the hospital, her baby was nursing well. Presently, her baby is feeding on demand, has gained appropriate weight, and is thriving.

Jane's obstetric history was unremarkable except for one episode of mastitis at 3 months postpartum, 2 years ago, which was treated with antibiotics.

On physical examination, Jane was found to be afebrile. She had inflamed nipples bilaterally. The areolae were red with flaky, shiny skin. No cracks were found. The breasts were normal without erythema, lumps, or tenderness. Immediately after Jane removed her bra, the midwife observed the nipples for color changes. She also applied a cold water application on the nipples to test for vasospasm, and cyanosis was not detected. The baby's mouth had no signs of thrush. Jane's midwife diagnosed her with presumptive candida of the nipple.

Jane was given a prescription of miconazole (Monistat-Derm) cream 2% and directed to apply the cream after every feeding. She was advised to wash her hands well before feedings, wash all her bras and clothing, keep her nipples dry, change nipple pads frequently, and clean all pacifiers, pumps, nipple shields, and shells if she uses them. Her baby was referred to her pediatrician for treatment, and the baby received oral nystatin (Mycostatin).

Jane returned to the office 3 weeks later and reported she found relief for about 2 weeks. Subsequently, she has developed deep, stabbing pain radiating toward her back during and after each feeding and burning of the nipples has returned. She denied fever, chills, lumps, or malaise. She was very frustrated and she wanted to stop nursing.

On examination, Jane was afebrile. Her nipples were red, inflamed, and tender to touch. Her breasts appeared normal without erythema, tenderness, or lumps. She was diagnosed with presumptive nipple and ductal candida. Jane received a prescription for fluconazole (Diflucan) 200 mg for one loading dose, followed by 200 mg once a day for 14 days. The baby was referred to her pediatrician and started on nystatin (Mycostatin) again. Jane returned 2 weeks after treatment. She was well and nursing her baby without difficulty.

*Jane is a composite patient.

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