Breast Pain and Nipple Pruritus in a Lactating Mother
The most likely diagnosis is mammary candidiasis (nipple thrush), and treatment should include topical antifungal therapy for both mother and infant, with oral fluconazole (100 mg/day for 7-14 days) reserved for cases unresponsive to topical therapy. 1
Most Likely Diagnosis: Mammary Candidiasis
Nipple pruritus combined with breast pain during lactation strongly suggests Candida albicans infection. 1 The classic presentation includes:
- Nipple or breast pain that worsens or is precipitated by nursing 1
- Pruritus over the nipple area (a distinguishing feature) 2
- Absence of classical mastitis findings (no fever, minimal physical examination findings) 1
- The infant may or may not show signs of oral or cutaneous candidiasis 1
While microbiological studies often find both bacteria and C. albicans (with bacteria predominating), treatment with antifungal agents has produced symptom relief in multiple reports. 1
Treatment Approach
First-Line Management
Topical antifungal therapy for both mother and infant:
- Apply nystatin cream or miconazole to the nipples after each feeding 1, 2
- Treat the infant's mouth with nystatin suspension (100,000 U/mL, 4-6 mL four times daily) even if no visible thrush is present 1
- Continue treatment for 7-14 days 1
Second-Line Management (If Topical Therapy Fails)
Oral fluconazole is as effective as—and in some studies superior to—topical therapy:
- Fluconazole 100 mg/day for 7-14 days for the mother 1
- This systemic approach is particularly useful when topical therapy has been inadequate 1
Supportive Measures
- Keep nipples clean and dry between feedings 3
- Avoid occlusive breast pads that trap moisture 2
- NSAIDs (ibuprofen or naproxen) for pain relief 4
- Ensure proper infant latch and positioning (poor latch is the most common cause of nipple pain but typically does not cause pruritus) 2, 3
Critical Differential Diagnoses to Consider
Raynaud's Phenomenon of the Nipple
- Presents with severe, throbbing pain precipitated by cold exposure 5
- Characteristic biphasic or triphasic color changes (blanching followed by cyanosis and/or erythema) 5
- Pain often mistaken for candidiasis, leading to inappropriate repeated antifungal treatment 5
- Treatment: nifedipine provides prompt relief 5
- Key distinguishing feature: pruritus is NOT a feature of Raynaud's phenomenon 5
Bacterial Infection (Mastitis)
- Typically presents with fever, erythema, warmth, and systemic symptoms 4
- Absence of these features makes bacterial mastitis less likely 1
- If positive culture for Staphylococcus aureus is obtained, systemic antibiotics are indicated 3
Irritant or Allergic Contact Dermatitis
- Can cause nipple pruritus and pain 2
- Consider if patient is using new topical products, breast pads, or laundry detergents 2
- Treatment involves identifying and removing the offending agent 2
Atopic Dermatitis
- May flare during lactation 2
- Usually associated with personal or family history of atopy 2
- Responds to emollients and low-potency topical corticosteroids 2
Common Pitfalls to Avoid
- Do not dismiss nipple pain as "normal" breastfeeding discomfort when pruritus is present—pruritus suggests infection or dermatitis. 2
- Do not treat repeatedly with antifungals without reassessing the diagnosis if symptoms persist beyond 7-14 days—consider Raynaud's phenomenon or other causes. 5
- Do not forget to treat the infant even if oral thrush is not visible—subclinical colonization can perpetuate maternal infection. 1
- Most nipple pain (without pruritus) resolves to mild levels by 7-10 days postpartum with proper positioning alone—persistent or worsening pain requires specific diagnosis. 6