Nipple candidiasis

• nipple pain in a breast-feeding woman may be a presentation of nipple thrush - however confirmation of the diagnosis is very difficult
• clinical features suggestive of nipple thrush include:
  • pain that gets worse after a breast-feed and increases for up to two hours
  • thrush is more likely after antibiotic usage; or if there is poor positioning with a history of cracked nipples; or if the woman has a history of this condition
  • this condition produces no pyrexia and no redness of the breast area; the areolae may show no colour loss, may be red or shiny
• differential diagnosis of nipple candidiasis
  • sore nipples are the most common breastfeeding problem in the first few days after birth
    • generally transient and resolves with proper positioning and latch on of the baby to the nipple
  • persistent pain without improvement needs to be evaluated
    • possible causes include
      • eczema of the areola and nipple
      • Raynaud's syndrome of the nipple
      • bacterial infection of the nipple - presents with red, inflamed, cracked nipples with or without exudates or fever
    • note that on occasion, nipples with any one of these syndromes can also appear normal, which makes diagnosis challenging (2)
• diagnosis:
  • a study has evaluated the sensitivity, specificity, positive predictive value, and likelihood ratios of signs and symptoms of mammary candidosis based on the presence of Candida species on the nipple/areola or in the milk
    • in this prospective cohort study, the nipple/areola skin and milk of 100 healthy breastfeeding mothers were cultured from each breast at 2 weeks postpartum, and mothers were interviewed regarding signs and symptoms associated with mammary candidosis between 2 and 9 weeks postpartum
    • positive predictive value for Candida colonization was highest when there were 3 or more signs or symptoms simultaneously or when flaky or shiny skin of the nipple/areola was reported together or in combination with breast pain
      • sore + burning + pain + stabbing + skin changes* combination had 100 % positive predictive value (PPV)
      • burning + pain + stabbing + skin changes combination had 100% PPV
      • pain + stabbing + skin changes combination had 100% PPV
  • note also that 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
• treatment:
  • apply miconazole cream after every feed and remove any residual cream before the next feed
  • 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
  • a US review suggests that persistent cases of nipple yeast or presumptive ductal yeast are frequently treated with oral fluconazole (2)
    • 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
  • the baby should be treated concurrently e.g. with nystatin suspension
  • if there is no improvement after 5 days then the diagnosis may be incorrect and should be re-examined

Notes:

• skin changes can be further subdivided into shiny skin of the nipple or flaky skin on the nipple-areola

The respective summary of product characteristics must be consulted before prescribing any of the medication mentioned.

Reference:

1. Pulse 2001; 61 (48):76.
2. Weiner S. Diagnosis and management of Candida of the nipple and breast. J Midwifery Womens Health. 2006 Mar-Apr;51(2):125-8.
3. Francis-Morrill J et al.Diagnostic value of signs and symptoms of mammary candidosis among lactating women.J Hum Lact 2004;20:288–295.