What is the treatment for breast yeast infections?

Treatment of Breast Yeast Infections

Breast yeast infections should be treated with topical azole antifungals or oral fluconazole, with both options providing effective relief in 80-90% of uncomplicated cases. 1

Diagnosis

• Diagnosis of breast candidiasis is made when a woman presents with symptoms such as burning, stinging pain radiating from the nipples into the breast during and after feedings, along with visible signs like cracked nipples 2
• Confirmation may include visualization of yeast or pseudohyphae in wet preparations with 10% KOH or positive culture for yeast species 1
• It's important to note that other conditions may mimic yeast infections, including subacute mastitis, dermatitis, vasospasm, and nipple blebs 3

Treatment Options

Topical Treatments

• First-line therapy includes topical azole antifungals applied to the nipple/areola area:
  • Clotrimazole 1% cream applied to nipples after feedings 1, 4
  • Miconazole 2% cream applied to nipples after feedings 1
  • Nystatin cream applied to nipples after feedings 2

Oral Treatment

• Fluconazole 150 mg as a single dose for uncomplicated cases 1
• For persistent cases, extended regimens may be necessary:
  • Fluconazole 200 mg loading dose followed by 100-200 mg daily for 2-6 weeks 2, 5
  • A study found women required between 1-29 fluconazole capsules (mean 7.3, median 6) for complete resolution 5

Treatment Algorithm

1. For mild to moderate cases:

   • Begin with topical azole antifungal (clotrimazole 1% or miconazole 2%) applied to nipples after each feeding 1
   • Continue treatment for 7-14 days 6

2. For severe or persistent cases:

   • Add oral fluconazole 150 mg as a single dose 1
   • If symptoms persist, consider extended fluconazole treatment (200 mg loading dose followed by 100-200 mg daily) 2, 5
   • Continue until symptoms resolve, typically 2-6 weeks 2

3. For recurrent infections:

   • Longer duration of therapy is required 1
   • Consider maintenance therapy with fluconazole 150 mg weekly for up to 6 months 1

Important Considerations

• Treat both mother and infant simultaneously to prevent reinfection, as the infant may be colonized even if asymptomatic 2, 4
• For infants, nystatin oral suspension (100,000 units/mL) applied to oral mucosa 4 times daily is recommended 2
• Topical azole creams should be wiped off before breastfeeding if applied shortly before 1
• Oil-based creams and suppositories may weaken latex condoms and diaphragms 6

Follow-Up

• Patients should return for follow-up only if symptoms persist after completing treatment or if symptoms recur 1
• If symptoms don't improve within 7-14 days of appropriate treatment, reconsider the diagnosis, as a recent study found that many cases of persistent nipple and breast pain attributed to Candida were actually other conditions 3

Common Pitfalls

• Misdiagnosis: Not all nipple/breast pain during lactation is due to yeast infection. Consider other diagnoses if treatment fails 3
• Inadequate treatment duration: Many women require more than the standard short course of antifungals 5
• Failure to treat both mother and infant: This can lead to reinfection and persistent symptoms 4
• Premature discontinuation of therapy: Complete the full course even if symptoms improve 1