When are analgesics, antifungal medications and antibiotics indicated in management of nipple pain and wounds?

Anti-inflammatories or analgesics

Ibuprofen may be used for lactation-related nipple pain. However, if the woman is taking more than an occasional dose of anti-infammatories, the NDC guidelines recommend that the clinician discusses with her whether it is time to consider nipple rest, discussed here.

Using pain relief that is effective during breastfeeding may interfere with a woman’s capacity to notice small changes in nipple sensation as she experiments with micromovements. Yet responsiveness to pain signals is very important if she is to eliminate repetitive mechanical microtrauma.

If the pain is so severe that a woman can’t imagine breastfeeding without analgesia, her nipples require complete rest from direct breastfeeding.

Topical or oral antifungals

A standard course of antifungal treatment may occasionally have a role for nipples which have been kept moist, humid, and warm for long periods. You can click here to read a history of the overtreatment of breastfeeding women with antifungals here.

On rare occasions, a one week trial of fluconazole may be indicated, to eliminate the possibility of nipple candidiasis in a woman with persistent nipple pain who has

• Taken antibiotics recently

• Preferred to keep her painful breasts in moisture-promoting contexts e.g. constant bra-wearing, not exposing breasts to the air at night

• High levels of use of lansinoh or hydrogel discs or silverettes or breast shells, which may cause a true candidiasis infection.

In this case, miconazole (Daktarin) oral gel can be painful to apply and worsens overhydration or moisture associated skin damage. The NDC Clinical Guidelines recommend fluconazole 150 mg every second day, for a total of three doses.

There is no reason to treat infant's oral cavity with antifungals, unless clinically obvious candida plaques is observed. This is not usually the case in association with nipple pain.

Prolonged treatment of the lactating woman is never required.7 You can find out about the pathogenic microbiota model of wound healing, and why it is falling out of favour, here.

Antibiotics

Exudate is commonly somewhat malodorous and may be coloured grey, green, or yellow. Management of an exudate is discussed here.

A clinician may decide that severely purulent exudate which is thick, gray green or yellow and has a strongly unpleasant odour warrants topical antibiotic treatment such as mupiricin, for 5-7 days.

Oral antibiotics are indicated if

• Cellulitis develops beyond the wound border, presenting as erythematous, spreading peri-wound inflammation and swelling, or

• For impetiginous changes of the nipple-areolar complex with weeping, yellow crusting blisters which do not respond to topical antibiotics.

Send off a swab for microscopy and culture prior to commencing oral antibiotics. It is likely that Staphylococcus aureus is found in a nipple wound, regardless of clinical presentation. However, taking a swab will alert the clinician to multi-resistant S aureus and need to change antibiotics.

The firstline antibiotic treatment is cefalexin 500 mg qid, unless the patient is allergic to pencillins. Please see the NDC Clinical Guidelines for Nipple Pain and Wounds here for further guidance.

Selected references

Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health. 2021;17:17455065211031480.

Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health. 2022;18:17455057221087865.