How to treat intermammary candidiasis with Nystatin powder under the breast?

Treatment of Intermammary Candidiasis with Nystatin Powder

For treating candidiasis under the breast (intermammary candidiasis), nystatin topical powder is the recommended first-line treatment, applied to clean, dry skin 2-3 times daily until the infection resolves, typically for 7-14 days. 1

Diagnosis and Clinical Presentation

• Intermammary candidiasis presents as erythematous, macerated skin in the inframammary fold with possible satellite lesions
• Diagnosis can be confirmed with KOH preparation showing pseudohyphae or yeast cells 2
• Symptoms typically include:
  • Redness and inflammation
  • Itching and burning sensation
  • Possible white patches or scaling
  • Maceration in skin folds
  • Satellite pustules at the periphery of the affected area

Treatment Protocol

Primary Treatment

1. Nystatin topical powder application:

   • Clean and thoroughly dry the affected area
   • Apply nystatin powder 2-3 times daily 1
   • Continue treatment for 7-14 days, even if symptoms improve earlier 2

2. Supportive measures:

   • Keep the area clean and dry between applications
   • Use absorbent cotton or soft cloth between skin folds to reduce moisture
   • Change undergarments frequently
   • Consider wearing cotton bras that lift and separate the breasts to reduce skin-to-skin contact

Alternative Options

If nystatin powder is ineffective or unavailable:

• Topical azoles (clotrimazole, miconazole) are effective alternatives 3
• For moderate to severe cases, oral fluconazole 150mg as a single dose may be considered 3

Special Considerations

For Recurrent Infections

• Address underlying risk factors:
  • Optimize glycemic control in diabetic patients 2
  • Weight reduction for obese patients 2
  • Consider cotton bras or breast supports that reduce skin-to-skin contact
  • Use moisture-absorbing powders preventively

For Resistant Cases

• Consider bacterial superinfection and treat accordingly
• For fluconazole-resistant Candida species (particularly C. glabrata), nystatin remains effective 4
• Complete the full course of treatment even if symptoms improve quickly 2

Evidence Quality and Considerations

Nystatin powder has demonstrated efficacy for cutaneous candidiasis in skin folds, particularly in obese and diabetic patients 3. The FDA-approved indication for nystatin topical powder specifically includes cutaneous or mucocutaneous mycotic infections caused by Candida albicans and other susceptible Candida species 1.

While comparative studies between nystatin and azoles show similar initial efficacy for candidal infections, nystatin has shown particular effectiveness against fluconazole-resistant Candida species 4, making it an excellent choice for intermammary candidiasis where resistance may be a concern.

Monitoring and Follow-up

• If no improvement is seen within 7 days, reassess the diagnosis
• Consider culture to identify possible resistant organisms
• Evaluate for concurrent bacterial infection if symptoms worsen or fail to improve
• For recurrent cases, implement preventive strategies and consider longer maintenance therapy

Remember that keeping the area dry is as important as the antifungal treatment itself 3, and addressing underlying conditions like diabetes or obesity is essential for preventing recurrence 2.