What are the possible causes of nipple discomfort?

Causes of Nipple Discomfort

Nipple discomfort arises from multiple distinct etiologies including inflammatory conditions (dermatitis, mastitis), infectious causes (bacterial more than fungal), mechanical factors (poor latch, friction), anatomical abnormalities (tongue tie, nipple blebs), vascular issues (vasospasm), and rarely malignancy—requiring systematic evaluation to identify the specific cause rather than empirically treating for presumed yeast infection. 1, 2

Inflammatory and Dermatologic Causes

Dermatitis (eczema) is a common cause of nipple pain that presents with erythema, pruritis, and sometimes scaling or crusting. 3, 4

• Atopic, irritant, and allergic contact dermatitis can all affect the nipple, often triggered by repetitive friction, chemical agents in soaps or detergents, or specific allergens. 3
• Nipple eczema requires topical corticosteroids or calcineurin inhibitors as first-line treatment, both safe during lactation, along with intensive moisturization and avoidance of provoking factors. 3
• Warm water or black tea compresses containing tannins can provide symptomatic relief. 3

Infectious Causes

Mastitis and breast abscess cause focal pain that may precede induration, redness, warmth, and fever, representing bacterial infection rather than fungal. 1

• Subacute mastitis/mammary dysbiosis is frequently misdiagnosed as Candida infection but responds to antibiotics and probiotics rather than antifungals. 2
• In a cohort of 25 women referred for "yeast" after failing antifungal therapy, zero were confirmed to have Candida, with diagnoses changed to subacute mastitis (n=8), nipple bleb (n=6), dermatitis (n=6), and other conditions. 2
• Candidal infection of the nipple is overdiagnosed—while historically linked to nipple pain in nursing mothers, microbiological studies show bacteria predominate over Candida, and the true cause of pain in this syndrome remains unclear. 1

Mechanical and Anatomical Factors

Incorrect positioning and attachment during breastfeeding is the most common attributed cause of nipple pain, followed by tongue tie. 5

• Tongue tie (ankyloglossia) restricts tongue movement and causes abnormal sucking mechanics leading to nipple trauma. 5
• Nipple blebs (blocked milk ducts at the nipple surface) cause focal sharp pain and require heat therapy or manual expression for resolution. 2
• Flat or inverted nipples can contribute to poor latch and subsequent nipple trauma. 5
• Repetitive friction from ill-fitting bras or during exercise can cause mechanical irritation. 3

Vascular Causes

Vasospasm of the nipple presents with intermittent blanching, color changes (white to blue to red), and burning pain, often triggered by cold exposure. 5, 2

• This condition is analogous to Raynaud phenomenon and requires warmth application and avoidance of cold triggers. 5

Structural Abnormalities

Palatal anomalies in the infant (high palate, cleft palate) alter sucking mechanics and cause nipple trauma. 5

Milk crust (dried milk on the nipple surface) can cause irritation and discomfort. 2

Referred Pain

Nerve irritation along the intercostal nerves (T3-T5) can cause referred pain perceived as nipple discomfort, including costochondritis, muscle strains, or nerve entrapment. 1

Rare but Serious Causes

Paget disease of the nipple (a form of breast cancer) can present with nipple eczema-like changes, requiring biopsy if unilateral, persistent, or not responding to standard eczema treatment. 3, 4

Advanced breast cancers, particularly invasive lobular carcinoma and anaplastic carcinoma, are disproportionately associated with breast and nipple pain compared to other cancer types. 1

Diagnostic Approach

When nipple pain persists despite initial management, consider dermatology referral, as 18 of 20 women with persistent sore nipples were successfully treated after dermatologic evaluation. 6

• Swabs for bacterial culture (not fungal) should be obtained if infection is suspected, as bacterial causes predominate. 2
• Punch or core needle biopsy is indicated when malignancy cannot be excluded clinically or when unilateral eczematous changes persist. 3, 2
• Milk culture has limited utility and was obtained in only 4 of 25 women in one cohort without changing management. 2

Common Pitfall

The most critical error is presumptively treating nipple pain as Candida infection without considering alternative diagnoses—all 25 women in one cohort who failed antifungal therapy had alternative diagnoses (subacute mastitis, dermatitis, nipple bleb, vasospasm, anatomical issues) and achieved symptom resolution within 2-42 days once correctly diagnosed and treated. 2