Treatment of Cracked Nipple with Purulent Discharge
Cracked nipples with purulent discharge should be treated with systemic oral antibiotics, specifically targeting Staphylococcus aureus, as topical antibiotics and optimal breastfeeding technique alone have poor healing rates and significantly increase the risk of mastitis. 1
Clinical Assessment and Diagnosis
Purulent discharge from cracked nipples represents S. aureus infection and should be diagnosed as a potentially widespread impetigo vulgaris requiring aggressive treatment. 1 This is distinct from physiologic nipple discharge, which is bilateral, from multiple ducts, and non-purulent. 2, 3
First-Line Treatment: Systemic Antibiotics
Oral antibiotics are the treatment of choice, with a 79% improvement rate compared to only 8% with optimal breastfeeding technique alone and 16-29% with topical antibiotics. 1
Antibiotic Selection:
- Flucloxacillin or dicloxacillin are appropriate first-line agents for S. aureus coverage 4, 1
- Treatment duration typically ranges from 7-10 days for uncomplicated cases 1
- Consider obtaining wound culture if available to confirm S. aureus and guide therapy 5
Why Topical Treatment Fails
Topical antibiotics (mupirocin, fusidic acid) and optimal breastfeeding techniques alone fail to heal most infected, cracked nipples. 1 The infection represents a deeper tissue process requiring systemic therapy rather than surface treatment.
Prevention of Mastitis
Systemic antibiotics significantly reduce mastitis risk from 12-35% in untreated patients to only 5% in those receiving oral antibiotics (p < 0.005). 1 This represents an ascending lactiferous duct bacterial infection that can be prevented with appropriate systemic treatment.
Adjunctive Measures
While systemic antibiotics are essential, supportive care includes:
- Warm water compresses for pain reduction 5
- Keeping nipples clean and dry 5
- Expressed breast milk application may reduce duration of cracked nipples 5
- Pain management with acetaminophen or NSAIDs; severe cases may require stronger analgesia (hydrocodone/acetaminophen was effective in one case) 4
Breastfeeding Considerations
Breastfeeding should generally continue during treatment, as systemic antibiotics are compatible with lactation. 1 However, if there is concern about HCV transmission risk (in HCV-positive mothers), specialist input should be sought for bleeding or cracked nipples. 6
Treatment Failure Considerations
If symptoms persist despite appropriate antibiotic therapy:
- Consider fungal superinfection (Candida), particularly if burning, stinging pain radiates into the breast and persists beyond feedings 4
- Fluconazole (200 mg loading dose, then 100-200 mg daily for 2-6 weeks) may be required for concurrent yeast infection 4
- Topical antifungal (nystatin ointment) can be added to nipples/areola 4
Common Pitfalls
- Avoid relying solely on topical antibiotics or breastfeeding technique optimization for infected cracked nipples with purulent discharge 1
- Do not delay systemic antibiotic treatment, as this increases mastitis risk substantially 1
- Healing may take several months even with appropriate treatment; set realistic expectations 4