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

Diagnosis and Management

The diagnosis and management of candida in the breastfeeding dyad are difficult because diagnosis is most often based on subjective signs and symptoms. Although there are many published articles about candida of the nipple and breast in medical and lay literature, most of the reports are anecdotal. A few studies have attempted to confirm diagnosis with microbiological testing.[11,12,13] Only one study has quantified signs and symptoms with sensitivity, specificity, and positive predictive values.[11] This prospective study by Francis-Morrill et al. cultured both the nipple and milk with a specific laboratory media from 100 healthy breastfeeding women at 2 weeks postpartum. The participants were examined for shiny or flaky skin of the nipple/areola and questioned about four symptoms of candida (burning pain of the nipple/areola, sore nipples, stabbing pain of the breast, and nonstabbing pain of the breast) at the time of culture and then again at 9 weeks postpartum. The signs and symptoms were correlated with culture results to determine the sensitivity, specificity, and negative and positive predictive values for each symptom. The positive predictive value was highest in women who had three or more signs or symptoms at the same time or when flaky shiny skin of the nipple/areola was seen in women who reported pain of the breast[11] ( Table 1 ).

Detection of Candida albicans in human milk is difficult to obtain because lactoferrin, which is present in human milk, has an inhibitory effect on the growth of candida.[1,14,15,16,17] The addition of iron to milk specimens significantly improves the yield of C. albicans on culture.[14] This method of culturing is selective and not readily available. Therefore, in the clinical setting, culturing candida is not beneficial unless specifically designed laboratory media are used to prevent lactoferrin from interfering with the growth of candida. However, if a bacterial infection is suspected and there is no response after treatment with antibiotics, then a breast milk culture and sensitivity testing should be performed.

History and Physical Examination

In addition to the physical examination, it is recommended that the breastfeeding mother have an examination by a lactation specialist or a practitioner knowledgeable about breastfeeding to evaluate her breastfeeding technique.

A complete history of pain, labor, delivery, and breastfeeding is essential, including the use of antibiotics in labor or postpartum, prior history of cracked nipples, and the infant's use of pacifiers and bottles.[18,19,20] Several studies suggest that vaginal yeast infections at the time of delivery, antibiotic therapy during labor or postpartum, and the use of bottles, pacifiers, and breast pumps are associated with mammary candidiasis. However, these risk factors, except for bottle use, have been identified in studies that used clinical data or patient self-reports to diagnose mammary candida.[12,13,19] In a study that confirmed diagnosis with laboratory findings, only a history of bottle use in the first 2 weeks postpartum was significantly associated with subsequent development of mammary candidosis (OR 6.4; CI 2.8-71.4; P < .001).1

A medical history to rule out risk factors for eczema of the nipple/areola and Raynaud's syndrome of the nipple should be included in the history. Observation of the nipple for signs of cyanosis is diagnostic for Raynaud's syndrome. Breastfeeding mothers have often been misdiagnosed and treated for candida when Raynaud's syndrome was the cause of nipple pain.[3]

Treatment of Nipple Candida

The pharmacologic treatment of candida of the nipple and ductal system is also problematic because of a lack of clinical trials. Several medications are used to treat candida of the nipples and breast, but none have been studied for the effect on mammary candida. The most common treatment for localized candida of the nipple is an antifungal, topical medication such as Nystatin (Mycostatin).[1,18,20] However, because more than 40% of yeasts are resistant to nystatin, it is recommended that miconazole (Monistat-Derm) or clotrimazole (Lotrimin or Mycelex) creams be used to treat the mother. The treatment plan often includes a topical antibiotic ointment because nipple fissures can concurrently present with candida of the nipples, and S. aureus is significantly associated with nipple fissures. Either mupirocin (Bactroban) or a triple antibiotic ointment, such as Neosporin ointment, can be prescribed.[4,21] For nipples that are very red and inflamed, a mid- or low-potency topical steroid cream can be used to facilitate healing.[17] Every treatment regimen must include the simultaneous treatment of the mother and baby dyad. Oral nystatin (Mycostatin Suspension) is the most common treatment for the baby, followed by oral fluconazole (Diflucan).[20,22]

Treatment of Ductal Candida

Persistent cases of nipple yeast or presumptive ductal yeast are frequently treated with oral fluconazole (Diflucan).[18,20] However, without clinical trials that document the efficacy and safety of fluconazole for mammary yeast, it is especially important to have a very high suspicion prior to treatment. Fluconazole is not approved by the Food and Drug Administration for mammary candidosis. The doses that are used, a 200- to 400-mg loading dose and then 100 to 200 mg once a day for 14 to 21 days, are doses that have been used to treat candidiasis infections in other organs (e.g., the bladder, esophagus, and liver) in immunocompromised persons.[23,24,25] In randomized controlled studies, the side effects from fluconazole at the aforementioned doses were minimal.[24] Fluconazole is often prescribed to continue for 1 to 2 weeks after symptoms have resolved to ensure cure and prevent reoccurrence.

It is recommended that breastfeeding continue while taking fluconazole. However, the nursing mother should be informed about the lack of data prior to prescribing this medication and weigh the benefits and risks of breastfeeding and weaning when using this medication. Fluconazole is contraindicated in pregnancy (category C) secondary to reports of teratogenicity in animal studies that used high concentrations of the drug. This medication does have drug-drug interactions and will increase plasma concentrations of phenytoin (Dilantin), warfarin (Coumadin), cisapride (Propulsid), and some sulfonylureas.[26] Consultation is recommended before prescribing fluconazole to women who are on other medications. It is excreted into breast milk in small amounts, approximately 1% of the maternal dose and less than 5% of the dose recommended for pediatric use. The medication is considered safe for a nursing infant.[27]

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