Start with local treatment consisting of:
1. Gentian violet (look under that title at the websites below). Once a day for 4 to 7 days. If pain gone after 4 days, stop gentian violet. If better, but not gone after four days, continue for 7 days. Stop after 7 days no matter what. If not better at all at 4 days, stop the gentian violet, continue with the ointment as below and call.
2. Nipple ointment as below:
mupirocin 2% ointment (15 grams)
nystatin 100,000 unit/ml ointment (15 grams)
betamethasone 0.1% ointment (15 grams)
The pharmacist mixes it all together and it is applied sparingly after each feeding (except the feeding when the mother uses gentian violet). Do not wash or wipe it off, even if the pharmacist asks you to. In Canada, Kenacomb (easier to find) or Viaderm KC (less expensive) ointment can be substituted for the above combination.
This is used until pain free and then decrease frequency over a week or two until stopped. (See Treatments for Problems 1 under “all purpose nipple ointment”).
3. If pain continues and it is sure the problem is Candida, or at least reasonably sure, add fluconazole 400 mg loading, then 100 mg twice daily for at least 2 weeks, until the mother is pain free for a week. The nipple ointment should be continued and the gentian violet can be repeated. If fluconazole too expensive, ketoconazole 400 mg loading, then 200 mg twice daily for same period of time (or grapefruit seed extract can be used). If Candida resistant, itraconazole, same dose and time period as fluconazole, though Candida actually is less sensitive to itraconazole, generally, than it is to fluconazole. (See handout Fluconazole). Fluconazole is apparently now available as a generic product (therefore less expensive). Fluconazole should not be used as a first line treatment or if nystatin alone does not work (which it usually doesn’t).
4. Grapefruit seed extract, 250 mg three times a day orally (taken by the mother), seems to work well in many cases. It can be used instead of fluconazole or in addition to fluconazole in resistant cases.
5. For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).
Written by Jack Newman, MD, FRCPC
May be copied and distributed without further permission