What are the ingredients and prescription for an all-purpose nipple ointment for a breastfeeding mother with nipple soreness or cracking?

All-Purpose Nipple Ointment (APNO) for Breastfeeding Mothers

All-purpose nipple ointment (APNO) is NOT superior to lanolin for treating painful, damaged nipples in breastfeeding mothers, and lanolin should be preferred as first-line therapy based on the highest quality randomized controlled trial evidence. 1

APNO Composition and Prescription

The standard APNO formulation contains three active ingredients combined in a compounded preparation 1:

• Mupirocin 2% (antibiotic)
• Betamethasone 0.1% (corticosteroid)
• Miconazole powder (antifungal)

These are typically compounded together in equal parts to create the ointment 1.

Evidence Against APNO as First-Line Treatment

The only randomized controlled trial directly comparing APNO to lanolin found no superiority of APNO and actually demonstrated better outcomes with lanolin 1:

• No significant difference in nipple pain scores at 1 week between APNO and lanolin groups 1
• Women using lanolin reported significantly greater satisfaction with their infant feeding method 1
• Lanolin users had nonsignificantly higher breastfeeding duration and exclusivity rates at 12 weeks postpartum 1

Recommended Treatment Algorithm

First-Line Therapy

Optimize breastfeeding technique FIRST, combined with lanolin and breast shells 2, 3:

• Correct infant latch and positioning is essential before any topical therapy 4, 5
• Apply lanolin cream after each feeding 2
• Use breast shells between feedings to protect healing nipples 2
• This combination is more effective than moist wound dressings and should remain first-line therapy 2

When to Escalate Treatment

If nipples show signs of bacterial infection (S. aureus), systemic oral antibiotics are required 3:

• Look for: persistent cracking, purulent discharge, worsening pain despite proper technique 3
• Topical antibiotics (mupirocin, fusidic acid) alone are insufficient - only 16-29% improvement versus 79% with oral antibiotics 3
• Systemic antibiotics reduce mastitis risk from 12-35% down to 5% 3
• Treating infected nipples as localized impetigo without systemic antibiotics leads to treatment failure 3

For Suspected Candidal Infection

If burning, stinging pain radiates into the breast and persists throughout and after feedings 6:

• Consider fluconazole 200 mg loading dose, then 100-200 mg daily for 2-6 weeks 6
• Concurrent topical antifungal (nystatin, miconazole) for 6-8 weeks may be needed 6
• Pain relief may require opioid analgesics (hydrocodone/acetaminophen) when over-the-counter medications fail 6

Critical Pitfalls to Avoid

• Never use moist wound dressings (hydrogel) - they have significantly higher infection rates and worse healing compared to lanolin and shells 2
• Do not rely on topical antibiotics alone for infected nipples - this leads to treatment failure and increased mastitis risk 3
• Recognize that complete healing may take several months even with appropriate treatment 7, 6
• If symptoms persist beyond 7 days despite treatment, consider biopsy to rule out Paget's disease 7

Special Populations

For mothers with Hepatitis C and cracked/bleeding nipples 7, 8:

• CDC recommends abstaining from breastfeeding if nipples are cracked or bleeding 7, 8
• Temporarily cease breastfeeding and express milk until complete healing occurs 7, 8

For mothers with Hepatitis B 7:

• Breastfeeding should not be discouraged unless mothers with detectable HBV DNA present with cracked nipples 7

Alternative Topical Agents

Peppermint gel may be superior to lanolin for prevention 9:

• Lower nipple crack rates than lanolin (RR 1.85 vs 2.41) 9
• Most effective when combined with proper breastfeeding technique instruction 9
• Consider for prophylactic use in primiparous mothers 9